Provider Demographics
NPI:1154511806
Name:CLASSIC CHIROPRACTIC P.S.
Entity Type:Organization
Organization Name:CLASSIC CHIROPRACTIC P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:ISAMU
Authorized Official - Last Name:KUNIKIYO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-458-3847
Mailing Address - Street 1:P.O.BOX 3082
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597
Mailing Address - Country:US
Mailing Address - Phone:360-400-2225
Mailing Address - Fax:360-400-2282
Practice Address - Street 1:35025 90TH AVE. S.
Practice Address - Street 2:UNIT 6
Practice Address - City:ROY
Practice Address - State:WA
Practice Address - Zip Code:98580
Practice Address - Country:US
Practice Address - Phone:360-400-2225
Practice Address - Fax:360-400-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHOOOO2656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty