Provider Demographics
NPI:1427509579
Name:REDMOND BACK AND NECK PAIN CLINIC
Entity type:Organization
Organization Name:REDMOND BACK AND NECK PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAGENER DEWOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-885-9950
Mailing Address - Street 1:16440 NE 85TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3613
Mailing Address - Country:US
Mailing Address - Phone:425-885-9950
Mailing Address - Fax:425-895-9766
Practice Address - Street 1:16440 NE 85TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3613
Practice Address - Country:US
Practice Address - Phone:425-885-9950
Practice Address - Fax:425-895-9766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001859111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G000105658Medicare UPIN