Healthcare Provider Details

I. General information

NPI: 1164599601
Provider Name (Legal Business Name): PUYALLUP CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EAST STEWART AVE
PUYALLUUP WA
98372
US

IV. Provider business mailing address

111 EAST STEWART AVE
PUYALLUP WA
98372
US

V. Phone/Fax

Practice location:
  • Phone: 253-845-0543
  • Fax: 253-848-6788
Mailing address:
  • Phone: 253-845-0543
  • Fax: 253-848-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00002891
License Number StateWA

VIII. Authorized Official

Name: DR. KEVIN LYNN TERRY
Title or Position: OWNER DOCTOR
Credential: DC
Phone: 253-845-0543