Provider Demographics
NPI:1346233103
Name:YOUNGBLOOD, HARLEY ORVILLE (DCRN)
Entity Type:Individual
Prefix:MR
First Name:HARLEY
Middle Name:ORVILLE
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:DCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11815 NE HIGHWAY 99
Mailing Address - Street 2:STE. A
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4008
Mailing Address - Country:US
Mailing Address - Phone:360-696-4405
Mailing Address - Fax:360-696-0582
Practice Address - Street 1:11815 NE HIGHWAY 99
Practice Address - Street 2:STE. A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-4008
Practice Address - Country:US
Practice Address - Phone:360-696-4405
Practice Address - Fax:360-696-0582
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA46659OtherL & I
115000330Medicare ID - Type Unspecified
WA46659OtherL & I