Provider Demographics
NPI:1811317548
Name:FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC
Entity type:Organization
Organization Name:FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:STILL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-636-2636
Mailing Address - Street 1:1815 HUDSON STREET
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-636-2636
Mailing Address - Fax:360-636-2621
Practice Address - Street 1:1815 HUDSON STREET
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-636-2636
Practice Address - Fax:360-636-2621
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY CHIROPRACTIC CARE BACK PAIN CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11155590OtherCAQH
WAG000700235Medicaid