Provider Demographics
NPI:1457959439
Name:CHAMPAGNE, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 TALLON LN NE STE D
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6607
Mailing Address - Country:US
Mailing Address - Phone:360-489-0973
Mailing Address - Fax:360-489-0983
Practice Address - Street 1:8825 TALLON LN NE STE D
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6607
Practice Address - Country:US
Practice Address - Phone:360-489-0973
Practice Address - Fax:360-489-0983
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61068859111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty