Provider Demographics
NPI:1508997214
Name:WASHOUGAL CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:WASHOUGAL CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:GIBBON
Authorized Official - Suffix:
Authorized Official - Credentials:DCND
Authorized Official - Phone:360-835-3150
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-0246
Mailing Address - Country:US
Mailing Address - Phone:360-835-3150
Mailing Address - Fax:360-835-0459
Practice Address - Street 1:1901 MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-4116
Practice Address - Country:US
Practice Address - Phone:360-835-3150
Practice Address - Fax:360-835-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001053111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000615103Medicare ID - Type Unspecified