Healthcare Provider Details

I. General information

NPI: 1861794182
Provider Name (Legal Business Name): PENINSULA CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 W PATISON ST
PORT HADLOCK WA
98339-9751
US

IV. Provider business mailing address

231 W PATISON ST
PORT HADLOCK WA
98339-9751
US

V. Phone/Fax

Practice location:
  • Phone: 360-385-4900
  • Fax: 360-385-3798
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30005953
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034364
License Number StateWA

VIII. Authorized Official

Name: DR. MICHAEL DAM
Title or Position: PRESIDENT
Credential: D.C.
Phone: 360-385-4900