1104988963 NPI number — CHEHALIS CHIROPRACTIC CLINIC, PS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104988963 NPI number — CHEHALIS CHIROPRACTIC CLINIC, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHEHALIS CHIROPRACTIC CLINIC, PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104988963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
876 S MARKET BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEHALIS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98532-3422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-748-1301
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
876 S MARKET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-748-1301
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHELTON
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
TIMOTHY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-748-1301

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH00002421 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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