Provider Demographics
NPI:1952779498
Name:A FAMILY & SPORTS CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:A FAMILY & SPORTS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYLLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-254-0400
Mailing Address - Street 1:5514 NE 107TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6346
Mailing Address - Country:US
Mailing Address - Phone:360-254-0400
Mailing Address - Fax:
Practice Address - Street 1:5514 NE 107TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6346
Practice Address - Country:US
Practice Address - Phone:360-254-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60200517111N00000X
WA2337111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000615536OtherMEDICARE PTAN
WAG8899092OtherMEDICARE PTAN