1306029954 NPI number — FIREWEED CHIROPRACTIC AND MASSAGE

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 1306029954 NPI number — FIREWEED CHIROPRACTIC AND MASSAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIREWEED CHIROPRACTIC AND MASSAGE
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:
1306029954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8800 GLACIER HWY STE 223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99801-8080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-790-4053
Provider Business Mailing Address Fax Number:
907-790-4054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8800 GLACIER HWY
Provider Second Line Business Practice Location Address:
SUITE 236, JORDAN CREEK CENTER
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-8087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-790-4053
Provider Business Practice Location Address Fax Number:
907-790-4054
Provider Enumeration Date:
12/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MELL
Authorized Official First Name:
KERI
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
907-790-4053

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  428 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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