Provider Demographics
NPI:1962898932
Name:VANQUAETHEM CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:VANQUAETHEM CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:VANQUAETHEM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-943-6206
Mailing Address - Street 1:1645 COOPER POINT RD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5735
Mailing Address - Country:US
Mailing Address - Phone:360-943-6206
Mailing Address - Fax:360-943-6276
Practice Address - Street 1:1645 COOPER POINT RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5735
Practice Address - Country:US
Practice Address - Phone:360-943-6206
Practice Address - Fax:360-943-6276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WATO2811Medicare UPIN