Provider Demographics
NPI:1609059096
Name:ANGELES CHIRPRACTIC CLINIC, P.S,
Entity Type:Organization
Organization Name:ANGELES CHIRPRACTIC CLINIC, P.S,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-457-3430
Mailing Address - Street 1:708 S RACE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6441
Mailing Address - Country:US
Mailing Address - Phone:360-457-3430
Mailing Address - Fax:360-457-7032
Practice Address - Street 1:708 S RACE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6441
Practice Address - Country:US
Practice Address - Phone:360-457-3430
Practice Address - Fax:360-457-7032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3164111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB33545Medicare UPIN