Provider Demographics
NPI:1164599601
Name:PUYALLUP CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:PUYALLUP CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-845-0543
Mailing Address - Street 1:111 EAST STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372
Mailing Address - Country:US
Mailing Address - Phone:253-845-0543
Mailing Address - Fax:253-848-6788
Practice Address - Street 1:111 EAST STEWART AVE
Practice Address - Street 2:
Practice Address - City:PUYALLUUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-845-0543
Practice Address - Fax:253-848-6788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WATE6127OtherREGENCE BLUE SHIELD
WATE6127OtherREGENCE BLUE SHIELD