Healthcare Provider Details

I. General information

NPI: 1902262835
Provider Name (Legal Business Name): CASCADIA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 172ND ST NE SUITE A
MARYSVILLE WA
98271-5484
US

IV. Provider business mailing address

1507 172ND ST NE SUITE A
MARYSVILLE WA
98271-5484
US

V. Phone/Fax

Practice location:
  • Phone: 360-652-7246
  • Fax: 360-654-0611
Mailing address:
  • Phone: 360-652-7246
  • Fax: 360-654-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberCX60618136
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60402217
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00001293
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00021076
License Number StateWA

VIII. Authorized Official

Name: DR. MICHAEL T BRENEMAN
Title or Position: OWNER/DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 360-652-7246