Provider Demographics
NPI:1992004592
Name:SURPRISE LAKE CHIROPRACTIC INC
Entity Type:Organization
Organization Name:SURPRISE LAKE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAMPINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-952-0302
Mailing Address - Street 1:2748 MILTON WAY
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-9382
Mailing Address - Country:US
Mailing Address - Phone:253-952-0302
Mailing Address - Fax:253-952-0307
Practice Address - Street 1:2748 MILTON WAY
Practice Address - Street 2:SUITE 211
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-9382
Practice Address - Country:US
Practice Address - Phone:253-952-0302
Practice Address - Fax:253-952-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty