Provider Demographics
NPI:1700134137
Name:WALL FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:WALL FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-692-5350
Mailing Address - Street 1:9621 MICKELBERRY RD NW
Mailing Address - Street 2:STE. 108
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8301
Mailing Address - Country:US
Mailing Address - Phone:360-692-5350
Mailing Address - Fax:360-692-5354
Practice Address - Street 1:9621 MICKELBERRY RD NW
Practice Address - Street 2:STE. 108
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8301
Practice Address - Country:US
Practice Address - Phone:360-692-5350
Practice Address - Fax:360-692-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60302851111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty