MEDICARE: EBENSTEINER CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	5583	OR

General Provider Information

NPI Number	:	1487058764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBENSTEINER CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	4111 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5342
Country	:	US
Telephone Number	:	503-281-3400
Fax Number	:	503-287-3787

Provider Business Practice Location Address
First Line	:	4111 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5342
Country	:	US
Telephone Number	:	503-281-3400
Fax Number	:	503-287-3787

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL EBENSTEINER
Credential	:
Telephone Number	:	503-593-8800

Provider Enumeration Date	:	10/16/2014
Last Update Date	:	03/12/2015

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