1619274081 NPI number — VAN FLEET CHIROPRACTIC PS

Table of content: (NPI 1619274081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619274081 NPI number — VAN FLEET CHIROPRACTIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VAN FLEET CHIROPRACTIC 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:
1619274081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 HUDSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-423-2037
Provider Business Mailing Address Fax Number:
360-423-9320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 HUDSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-423-2037
Provider Business Practice Location Address Fax Number:
360-423-9320
Provider Enumeration Date:
02/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VAN FLEET
Authorized Official First Name:
CLINTON
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
360-423-2037

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0004892 . This is a "L&I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2007250 . This is a "DSHS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8920472 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 350030478 . This is a "RAILROAD MM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G000700204 . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: T02610 . This is a "UPIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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