Provider Demographics
NPI:1639396203
Name:OCEAN BEACH CHIROPRACTIC PS
Entity Type:Organization
Organization Name:OCEAN BEACH CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-642-2474
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:167 FIRST AVENUE, NORTH
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0924
Mailing Address - Country:US
Mailing Address - Phone:360-642-2474
Mailing Address - Fax:360-642-2363
Practice Address - Street 1:167 FIRST AVENUE, NORTH
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-2474
Practice Address - Fax:360-642-2363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty