Provider Demographics
NPI:1992150346
Name:FERNDALE CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:FERNDALE CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONSTANTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-319-3485
Mailing Address - Street 1:PO BOX 1256
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-1256
Mailing Address - Country:US
Mailing Address - Phone:360-312-4656
Mailing Address - Fax:360-392-8732
Practice Address - Street 1:2376 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8605
Practice Address - Country:US
Practice Address - Phone:360-312-4656
Practice Address - Fax:360-392-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH0001782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA456782001OtherGROUP HEALTH
WA063990000OtherREGENCE BLUESHIELD
WA2091205Medicaid
WA456782001OtherGROUP HEALTH