1265576573 NPI number — PACIFIC CHIROPRACTIC CLINIC PLLC

Table of content: (NPI 1265576573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265576573 NPI number — PACIFIC CHIROPRACTIC CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC CHIROPRACTIC CLINIC PLLC
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:
1265576573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7503 196TH ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-5079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-775-8000
Provider Business Mailing Address Fax Number:
425-775-8221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7503 196TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98036-5079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-775-8000
Provider Business Practice Location Address Fax Number:
425-775-8221
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
O'HEA
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-775-8000

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 72790 . This is a "DEPT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12905 . This is a "AWHN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: R21556 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 13665 . This is a "AWHN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: R74350 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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