1871620773 NPI number — MIRACLE MILE CHIROPRACTIC PC

Table of content: (NPI 1871620773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871620773 NPI number — MIRACLE MILE CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE MILE CHIROPRACTIC 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:
1871620773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 HAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531-5202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-330-1312
Provider Business Mailing Address Fax Number:
360-330-1320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 KRESKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-3732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-330-1312
Provider Business Practice Location Address Fax Number:
360-330-1320
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-330-1312

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH00034048 , 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: CH00034049 , 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: 8349722 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB2803 . This is a "GROUP MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8869221 . This is a "CORP PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8903893 . This is a "L&I CRIME CHAD MILLS DC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0165763 . This is a "KRISTINA MILLS L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0165765 . This is a "CHAD MILLS L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8869913 . This is a "CHADS MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8870107 . This is a "KRISTINA MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8349730 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00096548 . This is a "CHAD MILLS DC RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0165764 . This is a "GROUP L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DB2803 . This is a "GROUP RAILRAOD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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