Provider Demographics
NPI:1932396785
Name:BONNEY LAKE CHIROPRACTIC INC, PS
Entity Type:Organization
Organization Name:BONNEY LAKE CHIROPRACTIC INC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-862-6662
Mailing Address - Street 1:9925 214TH AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-3910
Mailing Address - Country:US
Mailing Address - Phone:253-862-6662
Mailing Address - Fax:253-862-5553
Practice Address - Street 1:9925 214TH AVE E
Practice Address - Street 2:SUITE C
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-3910
Practice Address - Country:US
Practice Address - Phone:253-862-6662
Practice Address - Fax:253-862-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034053111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU86635Medicare UPIN