Provider Demographics
NPI:1104988963
Name:CHEHALIS CHIROPRACTIC CLINIC, PS
Entity type:Organization
Organization Name:CHEHALIS CHIROPRACTIC CLINIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-748-1301
Mailing Address - Street 1:876 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3422
Mailing Address - Country:US
Mailing Address - Phone:360-748-1301
Mailing Address - Fax:
Practice Address - Street 1:876 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3422
Practice Address - Country:US
Practice Address - Phone:360-748-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8864168Medicare PIN