Provider Demographics
NPI:1457489833
Name:EASTLAKE CHIROPRACTIC CENTER, PS
Entity Type:Organization
Organization Name:EASTLAKE CHIROPRACTIC CENTER, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-324-8600
Mailing Address - Street 1:112 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3419
Mailing Address - Country:US
Mailing Address - Phone:206-324-8600
Mailing Address - Fax:206-322-8520
Practice Address - Street 1:2722 EASTLAKE AVE E STE 360
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3143
Practice Address - Country:US
Practice Address - Phone:206-324-8600
Practice Address - Fax:206-322-8520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2489111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000108251Medicare ID - Type Unspecified
WAU11469Medicare UPIN