Provider Demographics
NPI:1376592915
Name:LAKE MERIDIAN CHIROPRACTIC
Entity Type:Organization
Organization Name:LAKE MERIDIAN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAGGAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-630-1575
Mailing Address - Street 1:25341 163RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7939
Practice Address - Country:US
Practice Address - Phone:253-630-1575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8851513Medicare PIN