Provider Demographics
NPI:1134487846
Name:PETTIBON CHIROPRACTIC CLINIC OF FEDERAL WAY INC.
Entity Type:Organization
Organization Name:PETTIBON CHIROPRACTIC CLINIC OF FEDERAL WAY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETTIBON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-839-5644
Mailing Address - Street 1:30804 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4902
Mailing Address - Country:US
Mailing Address - Phone:253-839-5644
Mailing Address - Fax:253-839-2625
Practice Address - Street 1:30804 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4902
Practice Address - Country:US
Practice Address - Phone:253-839-5644
Practice Address - Fax:253-839-2625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA199010175600BL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty