Provider Demographics
NPI:1588860613
Name:BOTEFUHR, CARL RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RUSSELL
Last Name:BOTEFUHR
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:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:SUQUAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98392-9702
Mailing Address - Country:US
Mailing Address - Phone:360-509-7147
Mailing Address - Fax:
Practice Address - Street 1:6505 NE PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SUQUAMISH
Practice Address - State:WA
Practice Address - Zip Code:98392-9702
Practice Address - Country:US
Practice Address - Phone:360-509-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor