Healthcare Provider Details

I. General information

NPI: 1043610116
Provider Name (Legal Business Name): MONROE CHIROPRACTIC AND MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 W MAIN ST
MONROE WA
98272-2028
US

IV. Provider business mailing address

1233 W MAIN ST
MONROE WA
98272-2028
US

V. Phone/Fax

Practice location:
  • Phone: 360-794-7115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM LANCE EBLEN
Title or Position: OWNER
Credential:
Phone: 360-794-7115