Provider Demographics
NPI:1790968188
Name:COLUMBIA POINT SPORTS REHABILITATION CLINIC CORP
Entity Type:Organization
Organization Name:COLUMBIA POINT SPORTS REHABILITATION CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-452-0738
Mailing Address - Street 1:408 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2816
Mailing Address - Country:US
Mailing Address - Phone:509-452-0738
Mailing Address - Fax:509-452-0743
Practice Address - Street 1:408 S 2ND ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2816
Practice Address - Country:US
Practice Address - Phone:509-452-0738
Practice Address - Fax:509-452-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229212OtherLABOR AND INDUSTRIES
WAG8871587Medicare PIN