Provider Demographics
NPI:1093887663
Name:CHIROPRACTIC HEALTHCARE CENTER, P S
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTHCARE CENTER, P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.C.
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:QUINT
Authorized Official - Last Name:COCKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-863-5323
Mailing Address - Street 1:15324 MAIN ST E STE B
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2698
Mailing Address - Country:US
Mailing Address - Phone:253-863-5323
Mailing Address - Fax:253-863-2034
Practice Address - Street 1:15324 MAIN ST E STE B
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2698
Practice Address - Country:US
Practice Address - Phone:253-863-5323
Practice Address - Fax:253-863-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034177111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA601367608OtherUBI NUMBER
WA119433OtherLNI GROUP
WACH00034177OtherLICENSE #
WA119433OtherLNI GROUP
WA=========OtherEIN
WACH00034177OtherLICENSE #
WA3500415669Medicare UPIN