Provider Demographics
NPI:1710032057
Name:ADVANCED CHIROPRACTIC CENTRE CORP
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC CENTRE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WASILENKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-892-3654
Mailing Address - Street 1:705 SE PARK CREST AVE., STE A120
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1303
Mailing Address - Country:US
Mailing Address - Phone:360-892-3654
Mailing Address - Fax:360-892-3692
Practice Address - Street 1:705 SE PARK CREST AVE., STE A120
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1303
Practice Address - Country:US
Practice Address - Phone:360-892-3654
Practice Address - Fax:360-892-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003418111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB36940Medicare ID - Type Unspecified