Healthcare Provider Details

I. General information

NPI: 1497933600
Provider Name (Legal Business Name): ODEGARD CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 STATE ST SUITE 3
KIRKLAND WA
98033-6615
US

IV. Provider business mailing address

433 STATE ST. SUITE 3
KIRKLAND WA
98033
US

V. Phone/Fax

Practice location:
  • Phone: 425-827-4646
  • Fax: 425-827-1941
Mailing address:
  • Phone: 425-827-4646
  • Fax: 425-827-1941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number1558
License Number StateWA

VIII. Authorized Official

Name: CARSON EDWARD ODEGARD
Title or Position: OWNER DOCTOR
Credential: D.C.
Phone: 425-827-4646