Provider Demographics
NPI:1063698231
Name:MCKENNA CHIROPRACTIC CENTER PS
Entity type:Organization
Organization Name:MCKENNA CHIROPRACTIC CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WINSLOW
Authorized Official - Last Name:SOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-400-2002
Mailing Address - Street 1:PO BOX 1370
Mailing Address - Street 2:
Mailing Address - City:MCKENNA
Mailing Address - State:WA
Mailing Address - Zip Code:98558-1370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9111 346TH ST S STE 3
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:WA
Practice Address - Zip Code:98580-8479
Practice Address - Country:US
Practice Address - Phone:360-400-2002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB34680Medicare PIN