Provider Demographics
NPI:1457539892
Name:MICHAEL CHURCH
Entity Type:Organization
Organization Name:MICHAEL CHURCH
Other - Org Name:CHURCH CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-841-4425
Mailing Address - Street 1:510 E MAIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5612
Mailing Address - Country:US
Mailing Address - Phone:253-841-4425
Mailing Address - Fax:253-445-5712
Practice Address - Street 1:510 E MAIN AVE STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-5612
Practice Address - Country:US
Practice Address - Phone:253-841-4425
Practice Address - Fax:253-445-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH3323111N00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA169571OtherGROUP WORKERS COMP