1811317548 NPI number — FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC

Table of content: (NPI 1811317548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811317548 NPI number — FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC
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:
1811317548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 HUDSON STREET
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-636-2636
Provider Business Mailing Address Fax Number:
360-636-2621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1815 HUDSON STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-636-2636
Provider Business Practice Location Address Fax Number:
360-636-2621
Provider Enumeration Date:
04/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STILL
Authorized Official First Name:
RICK
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-636-2636

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  CH00001766 , 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: 11155590 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: G000700235 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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