Provider Demographics
NPI:1124183850
Name:BLEVINS, GEORGE THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-5030
Mailing Address - Country:US
Mailing Address - Phone:360-426-6325
Mailing Address - Fax:360-426-8300
Practice Address - Street 1:422 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3410
Practice Address - Country:US
Practice Address - Phone:360-426-6325
Practice Address - Fax:360-426-8300
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA187046OtherL & I NUMBER
WA20-4226795OtherFEDERAL TAX ID
WA187046OtherL & I NUMBER