Provider Demographics
NPI:1235255662
Name:CHAN CHIROPRACTIC CLINIC, P.S.
Entity Type:Organization
Organization Name:CHAN CHIROPRACTIC CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-735-0311
Mailing Address - Street 1:4339 W KENNEWICK AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2802
Mailing Address - Country:US
Mailing Address - Phone:509-735-0311
Mailing Address - Fax:509-783-1206
Practice Address - Street 1:4339 W KENNEWICK AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2802
Practice Address - Country:US
Practice Address - Phone:509-735-0311
Practice Address - Fax:509-783-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA080370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB01981Medicare PIN