Provider Demographics
NPI:1497933600
Name:ODEGARD CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:ODEGARD CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ODEGARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-827-4646
Mailing Address - Street 1:433 STATE ST.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033
Mailing Address - Country:US
Mailing Address - Phone:425-827-4646
Mailing Address - Fax:425-827-1941
Practice Address - Street 1:433 STATE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6615
Practice Address - Country:US
Practice Address - Phone:425-827-4646
Practice Address - Fax:425-827-1941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1558302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487607164Medicare PIN