Provider Demographics
NPI:1669655056
Name:MOSES LAKE CHIROPRACTIC CENTER PS
Entity Type:Organization
Organization Name:MOSES LAKE CHIROPRACTIC CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MOSES LAKE CHIROPRACTIC P
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC DOCTOR OF CHIROPR
Authorized Official - Phone:509-765-9235
Mailing Address - Street 1:414 BEECH STREET
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1914
Mailing Address - Country:US
Mailing Address - Phone:509-765-9235
Mailing Address - Fax:509-765-9235
Practice Address - Street 1:414 BEECH STREET
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1914
Practice Address - Country:US
Practice Address - Phone:509-765-9235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U61618Medicare UPIN