Provider Demographics
NPI:1659741858
Name:CANYON CROSSING CHIROPRACTIC PS
Entity Type:Organization
Organization Name:CANYON CROSSING CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-208-0973
Mailing Address - Street 1:5610 176TH ST E
Mailing Address - Street 2:D105
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-9305
Mailing Address - Country:US
Mailing Address - Phone:847-208-0973
Mailing Address - Fax:
Practice Address - Street 1:5610 176TH ST E
Practice Address - Street 2:D105
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9305
Practice Address - Country:US
Practice Address - Phone:847-208-0973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH 60520744305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization