Provider Demographics
NPI:1144592981
Name:LEAVITT CHIROPRACTIC CLINIC INC. PS
Entity Type:Organization
Organization Name:LEAVITT CHIROPRACTIC CLINIC INC. PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-676-9533
Mailing Address - Street 1:1842 IRON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4646
Mailing Address - Country:US
Mailing Address - Phone:360-676-9533
Mailing Address - Fax:360-676-1581
Practice Address - Street 1:1842 IRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4646
Practice Address - Country:US
Practice Address - Phone:360-676-9533
Practice Address - Fax:360-676-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14434OtherLABOR & INDUSTRIES
WA2007953Medicaid
WAT03166Medicare UPIN
WAG001400451Medicare PIN