Provider Demographics
NPI:1366621021
Name:SOUTHSIDE CHIROPRACTIC INC.
Entity type:Organization
Organization Name:SOUTHSIDE CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KELLY - HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:CA
Authorized Official - Phone:360-671-8000
Mailing Address - Street 1:2616 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2409
Mailing Address - Country:US
Mailing Address - Phone:360-671-8000
Mailing Address - Fax:360-676-8591
Practice Address - Street 1:2616 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2409
Practice Address - Country:US
Practice Address - Phone:360-671-8000
Practice Address - Fax:360-676-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8800769OtherMEDICARE GROUP