Provider Demographics
NPI:1457490542
Name:35TH AVENUE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:35TH AVENUE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:LOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-932-8320
Mailing Address - Street 1:9455 35TH AVE SW
Mailing Address - Street 2:SUITE E
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3898
Mailing Address - Country:US
Mailing Address - Phone:206-932-8320
Mailing Address - Fax:206-932-6941
Practice Address - Street 1:9455 35TH AVE SW
Practice Address - Street 2:SUITE E
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3898
Practice Address - Country:US
Practice Address - Phone:206-932-8320
Practice Address - Fax:206-932-6941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1457490542OtherGROUP NPI
WA614143800OtherOWCP
WA1225012768OtherINDIVIDUAL NPI
WA5711LOOtherREGENCE BLUE SHIELD
WA0163578OtherLABOR & INDUSTRIES
WAG8863267Medicare PIN
WA614143800OtherOWCP
WAG8863268Medicare PIN