Provider Demographics
NPI:1639440084
Name:OLYMPIA CHIROPRACTIC CENTER PS
Entity type:Organization
Organization Name:OLYMPIA CHIROPRACTIC CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROYAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-943-8250
Mailing Address - Street 1:2716 PACIFIC AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-8804
Mailing Address - Country:US
Mailing Address - Phone:360-943-8250
Mailing Address - Fax:360-943-0473
Practice Address - Street 1:2716 PACIFIC AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-8804
Practice Address - Country:US
Practice Address - Phone:360-943-8250
Practice Address - Fax:360-943-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH1277261QM2500X
WACH60176120111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA22563OtherLABOR AND INDUSTRIES
WA019423001OtherGROUP HEALTH
WAG8901290Medicare UPIN
WA22563OtherLABOR AND INDUSTRIES