Provider Demographics
NPI:1336354000
Name:PHILLIPS CHIROPRACTIC CLINIC INC PS
Entity type:Organization
Organization Name:PHILLIPS CHIROPRACTIC CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JON
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-693-2597
Mailing Address - Street 1:6409 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7454
Mailing Address - Country:US
Mailing Address - Phone:360-693-2597
Mailing Address - Fax:360-695-0272
Practice Address - Street 1:6409 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7454
Practice Address - Country:US
Practice Address - Phone:360-693-2597
Practice Address - Fax:360-695-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA862111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0045101OtherL&I NUMBER
WA2708501Medicaid
WA0045101OtherL&I NUMBER