Provider Demographics
NPI:1821267659
Name:QUEEN ANNE CHIROPRACTIC INC, P.S.
Entity Type:Organization
Organization Name:QUEEN ANNE CHIROPRACTIC INC, P.S.
Other - Org Name:QUEEN ANNE CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:IRWIN
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-282-8275
Mailing Address - Street 1:1905 QUEEN ANNE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-2500
Mailing Address - Country:US
Mailing Address - Phone:206-282-8275
Mailing Address - Fax:206-282-8784
Practice Address - Street 1:1905 QUEEN ANNE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2500
Practice Address - Country:US
Practice Address - Phone:206-282-8275
Practice Address - Fax:206-282-8784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602380628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB11498Medicare PIN