Healthcare Provider Details

I. General information

NPI: 1093262842
Provider Name (Legal Business Name): DOUGLASS MCROBERTS KLOBUTCHER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 SE 164TH AVE STE 101
VANCOUVER WA
98684-9297
US

IV. Provider business mailing address

605 SE 164TH AVE STE 101
VANCOUVER WA
98684-9297
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-1205
  • Fax: 630-468-1478
Mailing address:
  • Phone: 360-567-1205
  • Fax: 630-468-1478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60683062
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: