1659741858 NPI number — CANYON CROSSING CHIROPRACTIC PS

Table of content: (NPI 1659741858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659741858 NPI number — CANYON CROSSING CHIROPRACTIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON CROSSING 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:
1659741858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5610 176TH ST E
Provider Second Line Business Mailing Address:
D105
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98375-9305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-208-0973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5610 176TH ST E
Provider Second Line Business Practice Location Address:
D105
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98375-9305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-208-0973
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-208-0973

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  CH 60520744 , 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)





Copyright © 2007-2025 www.npivalidator.com