Provider Demographics
NPI:1215104385
Name:WILLAMETTE FALLS CHIROPRACTIC CLINIC, LLC
Entity type:Organization
Organization Name:WILLAMETTE FALLS CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:IABONI
Authorized Official - Suffix:
Authorized Official - Credentials:DC, BSC
Authorized Official - Phone:503-656-1943
Mailing Address - Street 1:1609 WILLAMETTE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4544
Mailing Address - Country:US
Mailing Address - Phone:503-656-1943
Mailing Address - Fax:503-650-5808
Practice Address - Street 1:1609 WILLAMETTE FALLS DR
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4544
Practice Address - Country:US
Practice Address - Phone:503-656-1943
Practice Address - Fax:503-650-5808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR713327111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297980Medicaid