Provider Demographics
NPI:1023386695
Name:HEALTHY LIFESTYLE FAMILY CHIROPRACTIC PC CORPORATION
Entity Type:Organization
Organization Name:HEALTHY LIFESTYLE FAMILY CHIROPRACTIC PC CORPORATION
Other - Org Name:ORTING CHIROPRACTIC FAMILY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-893-8586
Mailing Address - Street 1:P O BOX 1596
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-1596
Mailing Address - Country:US
Mailing Address - Phone:360-893-8586
Mailing Address - Fax:360-893-3908
Practice Address - Street 1:218 WASHINGTON AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-9802
Practice Address - Country:US
Practice Address - Phone:360-893-8586
Practice Address - Fax:360-893-3908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0297643OtherSTATE INDUSTRIAL
WAU61768Medicare UPIN