Provider Demographics
NPI:1992901326
Name:ACTIVE CHIROPRACTIC CLINIC PS
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC CLINIC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HERSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-473-3733
Mailing Address - Street 1:7910 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408
Mailing Address - Country:US
Mailing Address - Phone:253-473-3733
Mailing Address - Fax:253-473-9517
Practice Address - Street 1:7910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408
Practice Address - Country:US
Practice Address - Phone:253-473-3733
Practice Address - Fax:253-473-9517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty