Provider Demographics
NPI:1700974383
Name:OTHELLO CHIROPRACTIC PS
Entity Type:Organization
Organization Name:OTHELLO CHIROPRACTIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:P
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-488-0797
Mailing Address - Street 1:225 E. MAIN ST.
Mailing Address - Street 2:P.O. BOX 477
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-0477
Mailing Address - Country:US
Mailing Address - Phone:509-488-0797
Mailing Address - Fax:509-488-1123
Practice Address - Street 1:225 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-0477
Practice Address - Country:US
Practice Address - Phone:509-488-0797
Practice Address - Fax:509-488-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty