1467592741 NPI number — LAKE STEVENS CHIROPRACTIC, PLLC

Table of content: (NPI 1467592741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467592741 NPI number — LAKE STEVENS CHIROPRACTIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE STEVENS CHIROPRACTIC, 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:
6
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:
1467592741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 SR 9 NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE STEVENS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98258-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-334-5066
Provider Business Mailing Address Fax Number:
425-335-4787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 STATE ROUTE 9 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE STEVENS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98258-9484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-334-5066
Provider Business Practice Location Address Fax Number:
425-335-4787
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HANSON
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-334-5066

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH00001249 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH0002638 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH00000734 , 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)

  • Identifier: 11170071 . This is a "CAQH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2026931 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2016458 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8864765 . This is a "MEDICARE DR GADDIS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 13819800 . This is a "CAQH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12014 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2319903 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0291162 . This is a "DEPT. OF LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12346880 . This is a "CAQH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0353640 . This is a "DEPT. OF LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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