Healthcare Provider Details

I. General information

NPI: 1639396203
Provider Name (Legal Business Name): OCEAN BEACH CHIROPRACTIC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 FIRST AVENUE, NORTH
ILWACO WA
98624
US

IV. Provider business mailing address

PO BOX 186 167 FIRST AVENUE, NORTH
ILWACO WA
98624-0924
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-2474
  • Fax: 360-642-2363
Mailing address:
  • Phone: 360-642-2474
  • Fax: 360-642-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034693
License Number StateWA

VIII. Authorized Official

Name: DR. MATTHEW J REILLY
Title or Position: CEO
Credential: DC
Phone: 360-642-2474