Provider Demographics
NPI:1962725150
Name:DREAM DESTINY PC
Entity type:Organization
Organization Name:DREAM DESTINY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-321-1698
Mailing Address - Street 1:4330 S 179TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98188-4141
Mailing Address - Country:US
Mailing Address - Phone:563-321-1698
Mailing Address - Fax:
Practice Address - Street 1:4330 S 179TH ST
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98188-4141
Practice Address - Country:US
Practice Address - Phone:563-321-1698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003193111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty