Provider Demographics
NPI:1720400302
Name:FRY CHIROPRACTIC
Entity Type:Organization
Organization Name:FRY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-876-4120
Mailing Address - Street 1:4800 JACKSON AVE SE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-1109
Mailing Address - Country:US
Mailing Address - Phone:360-876-4120
Mailing Address - Fax:360-895-0496
Practice Address - Street 1:4800 JACKSON AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-1109
Practice Address - Country:US
Practice Address - Phone:360-876-4120
Practice Address - Fax:360-895-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA48492Medicare UPIN