Provider Demographics
NPI:1114052354
Name:COLVILLE CHIROPRACTIC CLINIC INC PS
Entity Type:Organization
Organization Name:COLVILLE CHIROPRACTIC CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-684-4456
Mailing Address - Street 1:165 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2845
Mailing Address - Country:US
Mailing Address - Phone:509-684-4456
Mailing Address - Fax:509-684-4456
Practice Address - Street 1:165 S OAK ST
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2845
Practice Address - Country:US
Practice Address - Phone:509-684-4456
Practice Address - Fax:509-684-4456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001798111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2004976Medicaid
WA2004976Medicaid