Provider Demographics
NPI:1386920171
Name:DR JUSTIN J FAVREAU PLLC
Entity type:Organization
Organization Name:DR JUSTIN J FAVREAU PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FAVREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-497-4962
Mailing Address - Street 1:1225 DEXTER AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-3518
Mailing Address - Country:US
Mailing Address - Phone:206-497-4962
Mailing Address - Fax:206-316-8655
Practice Address - Street 1:1225 DEXTER AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-3518
Practice Address - Country:US
Practice Address - Phone:206-497-4962
Practice Address - Fax:206-316-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0261812OtherLABOR AND INDUSTRIES - INDIVIDUAL
1023194339OtherINDIVIDUAL NPI
WA8870884OtherMEDICARE PTAN
WA0268936OtherLABOR AND INDUSTRIES - GROUP
WA0268936OtherLABOR AND INDUSTRIES - GROUP