Provider Demographics
NPI:1891861001
Name:PROVASOLI, ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PROVASOLI
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 1:1018 7TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1512
Mailing Address - Country:US
Mailing Address - Phone:360-459-8114
Mailing Address - Fax:360-493-8742
Practice Address - Street 1:1018 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1512
Practice Address - Country:US
Practice Address - Phone:360-459-8114
Practice Address - Fax:360-493-8742
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT03101Medicare UPIN