Provider Demographics
NPI:1366630089
Name:PLATEAU CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:PLATEAU CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FADDAH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-868-9593
Mailing Address - Street 1:22647 NE INGLEWOOD HILL RD
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7105
Mailing Address - Country:US
Mailing Address - Phone:425-868-9593
Mailing Address - Fax:425-868-6826
Practice Address - Street 1:22647 NE INGLEWOOD HILL RD
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7105
Practice Address - Country:US
Practice Address - Phone:425-868-9593
Practice Address - Fax:425-868-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH0002601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG217000142Medicare PIN