Provider Demographics
NPI:1477684231
Name:EAGLE HARBOR CHIROPRACTIC INC.P.S.
Entity Type:Organization
Organization Name:EAGLE HARBOR CHIROPRACTIC INC.P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PETHERAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-842-2702
Mailing Address - Street 1:748 WINSLOW WAY E
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2410
Mailing Address - Country:US
Mailing Address - Phone:206-842-2702
Mailing Address - Fax:
Practice Address - Street 1:748 WINSLOW WAY E
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2410
Practice Address - Country:US
Practice Address - Phone:206-842-2702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3554111N00000X
CA22433111N00000X
WA3595111N00000X
CA22670111N00000X
WAMA00014485225700000X
WAMA00019967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB34482Medicare ID - Type Unspecified