MEDICARE: CLOVER CREEK CHIROPRACTIC INC PC

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	111NX0100X	Occupational Health Chiropractor

General Provider Information

NPI Number	:	1629631684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOVER CREEK CHIROPRACTIC INC PC

Provider Business Mailing Address
First Line	:	6141 93RD ST SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-2401
Country	:	US
Telephone Number	:	253-584-3838
Fax Number	:	253-588-5115

Provider Business Practice Location Address
First Line	:	6141 93RD ST SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-2401
Country	:	US
Telephone Number	:	253-584-3838
Fax Number	:	253-588-5115

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	ERIK M WELLS
Credential	:	D.C.
Telephone Number	:	253-584-3838

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	06/07/2019

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