Provider Demographics
NPI:1174760201
Name:WAKELAND CHIROPRACTIC CENTER INC PS
Entity type:Organization
Organization Name:WAKELAND CHIROPRACTIC CENTER INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:WAKELAND
Authorized Official - Suffix:
Authorized Official - Credentials:BA, DC
Authorized Official - Phone:253-566-8800
Mailing Address - Street 1:6412 20TH STREET CT W
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6227
Mailing Address - Country:US
Mailing Address - Phone:253-566-8800
Mailing Address - Fax:253-566-7092
Practice Address - Street 1:6412 20TH STREET CT W
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6227
Practice Address - Country:US
Practice Address - Phone:253-566-8800
Practice Address - Fax:253-566-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002249111N00000X
WACH00002197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA53870OtherDEPARTMENT OF LABOR & INDUSTRIES
T86908OtherUPIN
U27683OtherUPIN
WA53870OtherDEPARTMENT OF LABOR & INDUSTRIES