Provider Demographics
NPI:1649680190
Name:DR WADE D BURBANK BS DC P S
Entity type:Organization
Organization Name:DR WADE D BURBANK BS DC P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BURBANK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-567-1739
Mailing Address - Street 1:6403 NE 117TH AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5560
Mailing Address - Country:US
Mailing Address - Phone:360-567-1739
Mailing Address - Fax:360-256-0300
Practice Address - Street 1:6403 NE 117TH AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5560
Practice Address - Country:US
Practice Address - Phone:360-567-1739
Practice Address - Fax:360-256-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00033654261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8879939Medicare PIN