Provider Demographics
NPI:1497816714
Name:MCCONNELL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MCCONNELL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-923-5555
Mailing Address - Street 1:4324 MARTIN WAY E STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5367
Mailing Address - Country:US
Mailing Address - Phone:360-923-5555
Mailing Address - Fax:360-413-1584
Practice Address - Street 1:4324 MARTIN WAY E STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5367
Practice Address - Country:US
Practice Address - Phone:360-923-5555
Practice Address - Fax:360-413-1584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU54611Medicare UPIN
WAG 8864460Medicare PIN