Provider Demographics
NPI:1699817197
Name:M & K ETC INC
Entity Type:Organization
Organization Name:M & K ETC INC
Other - Org Name:ELMA CHIROPTACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-482-5155
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541
Mailing Address - Country:US
Mailing Address - Phone:360-482-5155
Mailing Address - Fax:360-482-4155
Practice Address - Street 1:103 N 1ST STREET
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-482-5155
Practice Address - Fax:360-482-4155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003029111N00000X
UT2953781202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020535Medicaid
WA46871OtherL & I
WA346230001OtherGROUP HEALTH
WA2020535Medicaid
WAG8872156Medicare PIN