Provider Demographics
NPI:1417146606
Name:COLLEGE PLACE CHIROPRACTIC
Entity Type:Organization
Organization Name:COLLEGE PLACE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:REX
Authorized Official - Last Name:HAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-525-7661
Mailing Address - Street 1:716 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1519
Practice Address - Country:US
Practice Address - Phone:509-525-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95654Medicare UPIN
G8852038Medicare PIN
G8852039Medicare PIN