MEDICARE: 35TH AVENUE CHIROPRACTIC PLLC

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	CH00034106	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457490542	OTHER	WA	GROUP NPI
2	614143800	OTHER	WA	OWCP
3	1225012768	OTHER	WA	INDIVIDUAL NPI
4	5711LO	OTHER	WA	REGENCE BLUE SHIELD
5	0163578	OTHER	WA	LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1457490542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	35TH AVENUE CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	9455 35TH AVE SW
Second Line	:	SUITE E
City	:	SEATTLE
State	:	WA
Zip	:	98126-3898
Country	:	US
Telephone Number	:	206-932-8320
Fax Number	:	206-932-6941

Provider Business Practice Location Address
First Line	:	9455 35TH AVE SW
Second Line	:	SUITE E
City	:	SEATTLE
State	:	WA
Zip	:	98126-3898
Country	:	US
Telephone Number	:	206-932-8320
Fax Number	:	206-932-6941

Authorized Official
Title or Position	:	OWNER AND CHIROPRACTOR
Name	:	DR. ERIC RYAN LOBERG
Credential	:	D.C.
Telephone Number	:	206-932-8320

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/01/2010

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