Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 651486 | OR |
N | 111NI0013X | Independent Medical Examiner | 651486 | OR |
NPI | 1437448966 |
---|---|
Provider Name | Dr. Glen I. Berry |
First Address | Beaverton, OR 97005-2029 |
Second Address | Beaverton, OR 97005-2029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2011 |
Last Update Date | 05/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
133964 | (02) | OR |