Provider Demographics
NPI:1619274081
Name:VAN FLEET CHIROPRACTIC PS
Entity Type:Organization
Organization Name:VAN FLEET CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:W
Authorized Official - Last Name:VAN FLEET
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:360-423-2037
Mailing Address - Street 1:1060 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3103
Mailing Address - Country:US
Mailing Address - Phone:360-423-2037
Mailing Address - Fax:360-423-9320
Practice Address - Street 1:1060 HUDSON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3103
Practice Address - Country:US
Practice Address - Phone:360-423-2037
Practice Address - Fax:360-423-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004892OtherL&I
2007250OtherDSHS
WA8920472OtherCRIME VICTIMS
WA350030478OtherRAILROAD MM
WAG000700204OtherMEDICARE
WAT02610OtherUPIN