Provider Demographics
NPI:1467592741
Name:LAKE STEVENS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:LAKE STEVENS CHIROPRACTIC, PLLC
Other - Org Name:LAKE STEVENS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-334-5066
Mailing Address - Street 1:905 SR 9 NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9484
Mailing Address - Country:US
Mailing Address - Phone:425-334-5066
Mailing Address - Fax:425-335-4787
Practice Address - Street 1:905 STATE ROUTE 9 NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9484
Practice Address - Country:US
Practice Address - Phone:425-334-5066
Practice Address - Fax:425-335-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00000734111N00000X
WACH00001249111N00000X
WACH0002638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA11170071OtherCAQH
WA2026931Medicaid
WA2016458Medicaid
WA8864765OtherMEDICARE DR GADDIS
WA13819800OtherCAQH
WA12014OtherLABOR & INDUSTRIES
WA2319903Medicaid
WA0291162OtherDEPT. OF LABOR & INDUSTRIES
WA12346880OtherCAQH
WA0353640OtherDEPT. OF LABOR & INDUSTRIES
WA0291162OtherDEPT. OF LABOR & INDUSTRIES
WA11170071OtherCAQH
WAT02987Medicare UPIN
WA12014OtherLABOR & INDUSTRIES
WA2016458Medicaid
WA2026931Medicaid
WAG8951464Medicare PIN