Provider Demographics
NPI:1184757981
Name:COUNTRY CHIROPRACTIC CLINIC, PLLC
Entity type:Organization
Organization Name:COUNTRY CHIROPRACTIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-856-5562
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98235-0508
Mailing Address - Country:US
Mailing Address - Phone:360-856-5562
Mailing Address - Fax:360-856-4923
Practice Address - Street 1:22790 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8023
Practice Address - Country:US
Practice Address - Phone:360-856-5562
Practice Address - Fax:360-856-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8870740Medicare PIN
WA8807187Medicare ID - Type Unspecified
WAG8807187Medicare PIN