Provider Demographics
NPI:1407975337
Name:DABALOS CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:DABALOS CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DABALOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-766-9966
Mailing Address - Street 1:830 E. BROADWAY
Mailing Address - Street 2:PO BOX 1637
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-0255
Mailing Address - Country:US
Mailing Address - Phone:509-766-9966
Mailing Address - Fax:509-766-0083
Practice Address - Street 1:830 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5932
Practice Address - Country:US
Practice Address - Phone:509-766-9966
Practice Address - Fax:509-766-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029502Medicaid
WA2029502Medicaid