Provider Demographics
NPI:1700916855
Name:CROCKETT, RONALD M (DC)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:M
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4070 MACLEAY RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-5801
Mailing Address - Country:US
Mailing Address - Phone:503-371-9796
Mailing Address - Fax:503-371-8265
Practice Address - Street 1:4070 MACLEAY RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-5801
Practice Address - Country:US
Practice Address - Phone:503-371-9796
Practice Address - Fax:503-371-8265
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114500Medicare ID - Type UnspecifiedMEDICARE GRP#
ORR114501Medicare ID - Type UnspecifiedMEDICARE PROV#
ORT67544Medicare UPIN