Provider Demographics
NPI:1831496314
Name:CHITTENDEN CHIROPRACTIC PS
Entity Type:Organization
Organization Name:CHITTENDEN CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CHITTENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-581-1533
Mailing Address - Street 1:8905 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3109
Mailing Address - Country:US
Mailing Address - Phone:253-581-1533
Mailing Address - Fax:253-588-2145
Practice Address - Street 1:8905 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3109
Practice Address - Country:US
Practice Address - Phone:253-581-1533
Practice Address - Fax:253-588-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA001001817Medicare UPIN