Provider Demographics
NPI:1649318635
Name:KENT CHIROPRACTIC CLINIC PS
Entity type:Organization
Organization Name:KENT CHIROPRACTIC CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-642-4390
Mailing Address - Street 1:PO BOX D
Mailing Address - Street 2:
Mailing Address - City:SEAVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98644-0004
Mailing Address - Country:US
Mailing Address - Phone:360-642-4390
Mailing Address - Fax:
Practice Address - Street 1:4403 PACIFIC HIGHWAY
Practice Address - Street 2:
Practice Address - City:SEAVIEW
Practice Address - State:WA
Practice Address - Zip Code:98644-0004
Practice Address - Country:US
Practice Address - Phone:360-642-4390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025202111N00000X
WACH00001614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0017594OtherL & I