Provider Demographics
NPI:1205028826
Name:PREMIER CHIROPRACTIC 4 PLLC
Entity Type:Organization
Organization Name:PREMIER CHIROPRACTIC 4 PLLC
Other - Org Name:PACIFIC VILLAGE CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-614-4000
Mailing Address - Street 1:1299 156TH AVE NE STE 123
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-7562
Mailing Address - Country:US
Mailing Address - Phone:425-614-4000
Mailing Address - Fax:425-641-0880
Practice Address - Street 1:1299 156TH AVE NE STE 123
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-7562
Practice Address - Country:US
Practice Address - Phone:425-614-4000
Practice Address - Fax:425-641-0880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER CHIROPRACTIC & MASSAGE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-16
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034325111N00000X
WAMA00013538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602211018OtherUBI #
WA602211018OtherUBI #