Provider Demographics
NPI:1184884108
Name:VAN DRIESSCHE CHIROPRACTIC P.S.
Entity type:Organization
Organization Name:VAN DRIESSCHE CHIROPRACTIC P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:Y
Authorized Official - Last Name:VAN DRIESSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-290-1919
Mailing Address - Street 1:12704 MUKILTEO SPEEDWAY STE C
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5720
Mailing Address - Country:US
Mailing Address - Phone:425-290-1919
Mailing Address - Fax:425-353-9690
Practice Address - Street 1:12704 MUKILTEO SPEEDWAY STE C
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5720
Practice Address - Country:US
Practice Address - Phone:425-290-1919
Practice Address - Fax:425-353-9690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003284305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2019560Medicaid
WA217000719Medicare PIN