Provider Demographics
NPI:1558602458
Name:COPELAND, JUSTIN DAVID (DC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:COPELAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29020 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CARNATION
Mailing Address - State:WA
Mailing Address - Zip Code:98014-9600
Mailing Address - Country:US
Mailing Address - Phone:425-441-8158
Mailing Address - Fax:
Practice Address - Street 1:33627 SE REDMOND-FALL CITY RD
Practice Address - Street 2:
Practice Address - City:FALL CITY
Practice Address - State:WA
Practice Address - Zip Code:98024
Practice Address - Country:US
Practice Address - Phone:425-441-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60331402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8919357Medicare UPIN