Provider Demographics
NPI:1891892154
Name:CHURCH, MICHAEL LEE (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:CHURCH
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:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0250
Mailing Address - Country:US
Mailing Address - Phone:253-841-4425
Mailing Address - Fax:253-445-5712
Practice Address - Street 1:510 EAST MAIN AVE
Practice Address - Street 2:STE. A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-841-4425
Practice Address - Fax:253-445-5712
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022127Medicaid
WA124892OtherLABOR & INDUSTRIES
WACH5182OtherREGENCE BLUE SHIELD
WAABO6317Medicare ID - Type Unspecified
WACH5182OtherREGENCE BLUE SHIELD