Provider Demographics
NPI:1972723641
Name:SSFC PS
Entity Type:Organization
Organization Name:SSFC PS
Other - Org Name:STATE STREET FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-653-6010
Mailing Address - Street 1:919 STATE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4284
Mailing Address - Country:US
Mailing Address - Phone:360-653-6010
Mailing Address - Fax:360-653-6008
Practice Address - Street 1:919 STATE AVE STE 102
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4284
Practice Address - Country:US
Practice Address - Phone:360-653-6010
Practice Address - Fax:360-653-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty