Provider Demographics
NPI:1407207665
Name:FIRESIDE CHIROPRACTIC, L.L.C.
Entity Type:Organization
Organization Name:FIRESIDE CHIROPRACTIC, L.L.C.
Other - Org Name:FIRESIDE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-949-0936
Mailing Address - Street 1:PO BOX 1122
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-1122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4884
Practice Address - Country:US
Practice Address - Phone:360-949-0936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60538356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8948243Medicare PIN