Provider Demographics
NPI:1255440087
Name:BLUE STONE CHIROPRACTIC PS
Entity type:Organization
Organization Name:BLUE STONE CHIROPRACTIC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-822-1859
Mailing Address - Street 1:620 KIRKLAND WAY
Mailing Address - Street 2:STE 105
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6021
Mailing Address - Country:US
Mailing Address - Phone:425-822-1859
Mailing Address - Fax:425-822-2920
Practice Address - Street 1:620 KIRKLAND WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6021
Practice Address - Country:US
Practice Address - Phone:425-822-1859
Practice Address - Fax:425-822-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH34314111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA195357OtherL&I
WA195357OtherL&I
WAG8857453Medicare ID - Type UnspecifiedGROUP