Provider Demographics
NPI:1679693824
Name:FEDERAL WAY CHIROPRACTIC PS
Entity Type:Organization
Organization Name:FEDERAL WAY CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-838-0600
Mailing Address - Street 1:3301 SW 314TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-7831
Mailing Address - Country:US
Mailing Address - Phone:253-838-0600
Mailing Address - Fax:253-927-1300
Practice Address - Street 1:3301 SW 314TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-7831
Practice Address - Country:US
Practice Address - Phone:253-838-0600
Practice Address - Fax:253-927-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1427130459Medicare UPIN
WAAB29806Medicare ID - Type UnspecifiedMEDICARE NUMBER