Provider Demographics
NPI:1528843612
Name:SURPRISE LAKE CHIROPRACTIC, INC PC
Entity type:Organization
Organization Name:SURPRISE LAKE CHIROPRACTIC, INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONFIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-952-0302
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0228
Mailing Address - Country:US
Mailing Address - Phone:253-952-0302
Mailing Address - Fax:253-952-0307
Practice Address - Street 1:724 MERIDIAN E STE 1
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-9391
Practice Address - Country:US
Practice Address - Phone:253-952-0302
Practice Address - Fax:253-952-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty