Provider Demographics
NPI:1558586487
Name:FAIRWOOD CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:FAIRWOOD CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-226-1856
Mailing Address - Street 1:14410 SE PETROVITSKY RD
Mailing Address - Street 2:STE 109
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8900
Mailing Address - Country:US
Mailing Address - Phone:425-226-1856
Mailing Address - Fax:425-226-0231
Practice Address - Street 1:14410 SE PETROVITSKY RD
Practice Address - Street 2:STE 109
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-226-1856
Practice Address - Fax:425-226-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00070121OtherRAILROAD MEDICARE
WA122123OtherWA ST L & I
WAGAB04901Medicare PIN