Provider Demographics
NPI:1932397437
Name:PRO ACTIVE CHIROPRACTIC CLINIC PS
Entity Type:Organization
Organization Name:PRO ACTIVE CHIROPRACTIC CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:N
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-417-1600
Mailing Address - Street 1:934 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3910
Mailing Address - Country:US
Mailing Address - Phone:360-417-1600
Mailing Address - Fax:360-452-4411
Practice Address - Street 1:934 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3910
Practice Address - Country:US
Practice Address - Phone:360-417-1600
Practice Address - Fax:360-452-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2680111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB17299Medicare PIN
WAGAB35547Medicare PIN