Provider Demographics
NPI:1063693497
Name:WEIDER CHIROPRACTIC CLINIC,P.S.
Entity type:Organization
Organization Name:WEIDER CHIROPRACTIC CLINIC,P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WEIDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:360-452-2934
Mailing Address - Street 1:603 E 8TH ST
Mailing Address - Street 2:#D
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6251
Mailing Address - Country:US
Mailing Address - Phone:360-452-2934
Mailing Address - Fax:
Practice Address - Street 1:603 E 8TH ST
Practice Address - Street 2:#D
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6251
Practice Address - Country:US
Practice Address - Phone:360-452-2934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU59358Medicare UPIN
WAAB27148Medicare PIN