Provider Demographics
NPI:1578833372
Name:FOREST VILLA CHIROPRACTIC CENTER,INC P.S.
Entity Type:Organization
Organization Name:FOREST VILLA CHIROPRACTIC CENTER,INC P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FABIANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-833-3290
Mailing Address - Street 1:2801 AUBURN WAY S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-7961
Mailing Address - Country:US
Mailing Address - Phone:253-833-3290
Mailing Address - Fax:
Practice Address - Street 1:2801 AUBURN WAY S
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-7961
Practice Address - Country:US
Practice Address - Phone:253-833-3290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00000770111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000104563Medicare PIN