Provider Demographics
NPI:1710030358
Name:HINES, MARC DEWAYNE (DC)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:DEWAYNE
Last Name:HINES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12815 CANYON RD E
Mailing Address - Street 2:STE K
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5104
Mailing Address - Country:US
Mailing Address - Phone:253-256-4769
Mailing Address - Fax:253-268-2057
Practice Address - Street 1:12815 CANYON RD E
Practice Address - Street 2:SUITE I
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5786
Practice Address - Country:US
Practice Address - Phone:253-256-4769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB27135Medicare ID - Type Unspecified