Provider Demographics
NPI:1720251994
Name:FISHERS LANDING CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:FISHERS LANDING CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-253-9482
Mailing Address - Street 1:PO BOX 873546
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-3546
Mailing Address - Country:US
Mailing Address - Phone:360-253-9482
Mailing Address - Fax:360-253-5366
Practice Address - Street 1:916 SE 164TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9602
Practice Address - Country:US
Practice Address - Phone:360-253-9482
Practice Address - Fax:360-253-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0133632OtherLABOR & INDUSTRIES
WAU40763Medicare UPIN
WA0133632OtherLABOR & INDUSTRIES