Provider Demographics
NPI:1164701744
Name:RIVER CITY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:RIVER CITY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WICKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-241-3088
Mailing Address - Street 1:615 N SULLIVAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8574
Mailing Address - Country:US
Mailing Address - Phone:509-241-3088
Mailing Address - Fax:509-241-3089
Practice Address - Street 1:615 N SULLIVAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8574
Practice Address - Country:US
Practice Address - Phone:509-241-3088
Practice Address - Fax:509-241-3089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60139083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty