Provider Demographics
NPI:1083019301
Name:EDMONDS-WOODWAY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:EDMONDS-WOODWAY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:MARTY
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-742-1072
Mailing Address - Street 1:7631 212TH ST SW
Mailing Address - Street 2:105B
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7565
Mailing Address - Country:US
Mailing Address - Phone:903-742-1072
Mailing Address - Fax:425-775-9608
Practice Address - Street 1:7631 212TH ST SW
Practice Address - Street 2:105B
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7565
Practice Address - Country:US
Practice Address - Phone:903-742-1072
Practice Address - Fax:425-775-9608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60443467111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0325925OtherLABOR AND INDUSTRIES
WAG8928890Medicare UPIN