Provider Demographics
NPI:1932396652
Name:MOUNT VERNON CHIROPRACTIC, INC., P.S.
Entity Type:Organization
Organization Name:MOUNT VERNON CHIROPRACTIC, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FOCHESATO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-428-0304
Mailing Address - Street 1:1600 ROOSEVELT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2646
Mailing Address - Country:US
Mailing Address - Phone:360-428-0304
Mailing Address - Fax:360-428-0968
Practice Address - Street 1:1600 ROOSEVELT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2646
Practice Address - Country:US
Practice Address - Phone:360-428-0304
Practice Address - Fax:360-428-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002227111N00000X
WACH00034784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49111OtherLABOR AND INDUSTRIES
WA304854304854OtherPREMERA BLUE CROSS
WA8592FOOtherREGENCE BLUE SHIELD
WA49111OtherLABOR AND INDUSTRIES