MEDICARE: MAGNOLIA CHIROPRACTIC AND MASSAGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH 60067858	WA

General Provider Information

NPI Number	:	1396060661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA CHIROPRACTIC AND MASSAGE

Provider Business Mailing Address
First Line	:	3150 W GOVERNMENT WAY
Second Line	:	STE. A-2
City	:	SEATTLE
State	:	WA
Zip	:	98199-1459
Country	:	US
Telephone Number	:	360-969-0495
Fax Number	:

Provider Business Practice Location Address
First Line	:	3150 W GOVERNMENT WAY
Second Line	:	STE. A-2
City	:	SEATTLE
State	:	WA
Zip	:	98199-1459
Country	:	US
Telephone Number	:	360-969-0495
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN
Name	:	JOSHUA L PENNER
Credential	:	DC
Telephone Number	:	360-969-0495

Provider Enumeration Date	:	03/30/2010
Last Update Date	:	04/21/2010

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