Provider Demographics
NPI:1184897225
Name:GENESIS CHIROPRACTIC REHABILITATION NW INC
Entity type:Organization
Organization Name:GENESIS CHIROPRACTIC REHABILITATION NW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-256-4769
Mailing Address - Street 1:12815 CANYON RD E
Mailing Address - Street 2:SUITE K
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5104
Mailing Address - Country:US
Mailing Address - Phone:253-256-4769
Mailing Address - Fax:253-268-2057
Practice Address - Street 1:12815 CANYON RD E
Practice Address - Street 2:SUITE K
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5104
Practice Address - Country:US
Practice Address - Phone:253-256-4769
Practice Address - Fax:253-268-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB27135Medicare PIN