Provider Demographics
NPI:1922290279
Name:DEWILDE CHIROPRACTIC INC
Entity Type:Organization
Organization Name:DEWILDE CHIROPRACTIC INC
Other - Org Name:LIBERTY BAY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEWILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:360-779-7800
Mailing Address - Street 1:19740 7TH AVE NE # 9
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7571
Mailing Address - Country:US
Mailing Address - Phone:360-779-7800
Mailing Address - Fax:360-779-7060
Practice Address - Street 1:19740 7TH AVE NE # 9
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7571
Practice Address - Country:US
Practice Address - Phone:360-779-7800
Practice Address - Fax:360-779-7060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0188295OtherLABOR AND INDUSTRIES
WA8800886Medicare PIN