Provider Demographics
NPI:1225320096
Name:FAUNTLEROY CHIROPRACTIC, P.S.
Entity Type:Organization
Organization Name:FAUNTLEROY CHIROPRACTIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-932-6605
Mailing Address - Street 1:4520 FAUNTLEROY WAY SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-2740
Mailing Address - Country:US
Mailing Address - Phone:206-932-6605
Mailing Address - Fax:206-933-6999
Practice Address - Street 1:4520 FAUNTLEROY WAY SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2740
Practice Address - Country:US
Practice Address - Phone:206-932-6605
Practice Address - Fax:206-933-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH3113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty