Provider Demographics
NPI:1679641393
Name:CASCADE PARK SPORTS MEDICINE & REHAB CLINIC PLLC
Entity Type:Organization
Organization Name:CASCADE PARK SPORTS MEDICINE & REHAB CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:Q
Authorized Official - Last Name:HOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-254-4040
Mailing Address - Street 1:12214 SE MILL PLAIN BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6019
Mailing Address - Country:US
Mailing Address - Phone:360-254-4040
Mailing Address - Fax:360-253-7808
Practice Address - Street 1:12214 SE MILL PLAIN BLVD
Practice Address - Street 2:STE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6019
Practice Address - Country:US
Practice Address - Phone:360-254-4040
Practice Address - Fax:360-253-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB37764Medicare PIN