Provider Demographics
NPI:1407052350
Name:FAMILY CHIROPRACTIC AT SALMON CREEK INC
Entity Type:Organization
Organization Name:FAMILY CHIROPRACTIC AT SALMON CREEK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:III
Authorized Official - Credentials:RN ,DC,FICPA
Authorized Official - Phone:360-696-4405
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0046659OtherLABOR & INDUSTRIES
WAG11500030Medicare ID - Type Unspecified
WA0046659OtherLABOR & INDUSTRIES