Provider Demographics
NPI:1265576573
Name:PACIFIC CHIROPRACTIC CLINIC PLLC
Entity type:Organization
Organization Name:PACIFIC CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:O'HEA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-775-8000
Mailing Address - Street 1:7503 196TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5079
Mailing Address - Country:US
Mailing Address - Phone:425-775-8000
Mailing Address - Fax:425-775-8221
Practice Address - Street 1:7503 196TH ST SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5079
Practice Address - Country:US
Practice Address - Phone:425-775-8000
Practice Address - Fax:425-775-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA72790OtherDEPT OF LABOR
WA12905OtherAWHN
WAR21556OtherREGENCE BLUE SHIELD
WA13665OtherAWHN
WAR74350OtherREGENCE BLUE SHIELD
WA8859742Medicare PIN