Provider Demographics
NPI:1093953689
Name:MIDLAND CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:MIDLAND CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ULMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-535-0186
Mailing Address - Street 1:PO BOX 5202
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98064-5202
Mailing Address - Country:US
Mailing Address - Phone:253-520-0158
Mailing Address - Fax:253-854-9860
Practice Address - Street 1:10422 PORTLAND AVE E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-5240
Practice Address - Country:US
Practice Address - Phone:253-535-0186
Practice Address - Fax:253-535-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003281111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024255Medicaid
WAUL6768OtherREGENCE
WA109410OtherDLI
WA2024255Medicaid