Provider Demographics
NPI:1225159940
Name:PINE LAKE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:PINE LAKE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EMIL
Authorized Official - Last Name:BAHM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-391-4095
Mailing Address - Street 1:2908 228TH AVE SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9306
Mailing Address - Country:US
Mailing Address - Phone:425-391-4095
Mailing Address - Fax:425-391-6059
Practice Address - Street 1:2908 228TH AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9306
Practice Address - Country:US
Practice Address - Phone:425-391-4095
Practice Address - Fax:425-391-6059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002143111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1356433726OtherDAVID BAHM NPI
WA0038178OtherL AND I
WA2032670Medicaid
WA2032670Medicaid