Provider Demographics
NPI:1740477298
Name:CHIROPRACTIC SPORTS & FAMILY HEALTH CENTER, P.S.
Entity type:Organization
Organization Name:CHIROPRACTIC SPORTS & FAMILY HEALTH CENTER, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KVATERNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-438-9609
Mailing Address - Street 1:7267 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5534
Mailing Address - Country:US
Mailing Address - Phone:360-438-9609
Mailing Address - Fax:360-456-7380
Practice Address - Street 1:7267 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5534
Practice Address - Country:US
Practice Address - Phone:360-438-9609
Practice Address - Fax:360-456-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025202 CH00002200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007748Medicaid
WA0190622OtherWORKERS COMPENSATION
WA2007748Medicaid
WAG8851141Medicare PIN