Provider Demographics
NPI:1023194339
Name:FAVREAU, JUSTIN JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JOHN
Last Name:FAVREAU
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 1:1225 DEXTER AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109
Mailing Address - Country:US
Mailing Address - Phone:206-497-4962
Mailing Address - Fax:206-316-8655
Practice Address - Street 1:1225 DEXTER AVE NORTH
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:206-497-4962
Practice Address - Fax:206-316-8655
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034786111N00000X
CO6129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8870884OtherNORIDIAN MEDICARE PTAN
WA8870884OtherNORIDIAN MEDICARE PTAN