Provider Demographics
NPI:1699766576
Name:GOOD NEWS CHIROPRACTIC, INC,
Entity type:Organization
Organization Name:GOOD NEWS CHIROPRACTIC, INC,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-771-1010
Mailing Address - Street 1:3318 SE 156TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2119
Mailing Address - Country:US
Mailing Address - Phone:503-771-1010
Mailing Address - Fax:503-771-5504
Practice Address - Street 1:3318 SE 156TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2119
Practice Address - Country:US
Practice Address - Phone:503-771-1010
Practice Address - Fax:503-771-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272867111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR061924Medicaid
OR061924Medicaid
104478Medicare ID - Type UnspecifiedPROVIDER NUMBER
104477Medicare ID - Type UnspecifiedGROUP NUMBER