Provider Demographics
NPI:1659442135
Name:WASILENKOFF, LARRY LEE (DC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:WASILENKOFF
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 1:705 SE PARK CREST AVE STE A120
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1303
Mailing Address - Country:US
Mailing Address - Phone:360-892-3654
Mailing Address - Fax:360-892-3692
Practice Address - Street 1:705 SE PARK CREST AVE STE A120
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1303
Practice Address - Country:US
Practice Address - Phone:360-892-3654
Practice Address - Fax:360-892-3692
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB36939Medicare ID - Type Unspecified