Healthcare Provider Details

I. General information

NPI: 1285266080
Provider Name (Legal Business Name): E GROUP WA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 NE FOURTH PLAIN BLVD STE B
VANCOUVER WA
98662-6314
US

IV. Provider business mailing address

11015 NE FOURTH PLAIN BLVD STE B
VANCOUVER WA
98662-6314
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-0451
  • Fax: 360-892-1601
Mailing address:
  • Phone: 360-892-0451
  • Fax: 360-892-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIK LEAVITT
Title or Position: OWNER
Credential: DC
Phone: 360-892-1601