Provider Demographics
NPI:1104991033
Name:ADVANCED CHIROPRACTIC HEALTH & WELLNESS CENTER
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC HEALTH & WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-893-8586
Mailing Address - Street 1:218 WASHINGTON AVENUE S
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-1596
Mailing Address - Country:US
Mailing Address - Phone:360-893-8586
Mailing Address - Fax:360-893-3908
Practice Address - Street 1:218 WASHINGTON AVENUE S
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-1596
Practice Address - Country:US
Practice Address - Phone:360-893-8586
Practice Address - Fax:360-893-3908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA611323100OtherDEPARTMENT OF LABOR
WAMU6654OtherBLUE SHIELD
WA0005222583OtherAETNA
WA0152163OtherSTATE INDUSTRIAL
WA2026375Medicaid
WAP00294932OtherRAILROAD MEDICARE
WAMU6654OtherBLUE SHIELD