Provider Demographics
NPI:1699079475
Name:LAURENCE FENN BOURLAND JR. , D.C., P.C.
Entity type:Organization
Organization Name:LAURENCE FENN BOURLAND JR. , D.C., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:FENN
Authorized Official - Last Name:BOURLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:503-640-2614
Mailing Address - Street 1:1623 SE ENTERPRISE CIR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-5064
Mailing Address - Country:US
Mailing Address - Phone:503-640-2614
Mailing Address - Fax:503-648-2637
Practice Address - Street 1:1623 SE ENTERPRISE CIR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-5064
Practice Address - Country:US
Practice Address - Phone:503-640-2614
Practice Address - Fax:503-648-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1194111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0000QGBBDMedicare UPIN