Provider Demographics
NPI:1083899066
Name:BLACKBURN CLINIC, INC. PS
Entity Type:Organization
Organization Name:BLACKBURN CLINIC, INC. PS
Other - Org Name:REBOUND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:253-854-8880
Mailing Address - Street 1:11107 SE KENT KANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7707
Mailing Address - Country:US
Mailing Address - Phone:253-854-8880
Mailing Address - Fax:253-854-7160
Practice Address - Street 1:11107 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7707
Practice Address - Country:US
Practice Address - Phone:253-854-8880
Practice Address - Fax:253-854-7160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034702111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty