Provider Demographics
NPI:1508053497
Name:GENESIS CHIROPRACTIC CENTER INC PS
Entity Type:Organization
Organization Name:GENESIS CHIROPRACTIC CENTER INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-380-4848
Mailing Address - Street 1:PO BOX 2098
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-2098
Mailing Address - Country:US
Mailing Address - Phone:360-380-4848
Mailing Address - Fax:
Practice Address - Street 1:5630 3RD ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248
Practice Address - Country:US
Practice Address - Phone:360-380-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty