Healthcare Provider Details

I. General information

NPI: 1568906030
Provider Name (Legal Business Name): NEW SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2016
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 RIVERSIDE DR STE 105
MOUNT VERNON WA
98273-5454
US

IV. Provider business mailing address

2118 RIVERSIDE DR STE 105
MOUNT VERNON WA
98273-5454
US

V. Phone/Fax

Practice location:
  • Phone: 360-424-6104
  • Fax:
Mailing address:
  • Phone: 360-424-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberCH60562639
License Number StateWA

VIII. Authorized Official

Name: DR. BASIL ABUID
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 360-424-6104