Healthcare Provider Details

I. General information

NPI: 1699199109
Provider Name (Legal Business Name): BEACON CHIROPRACTIC CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 NE 119TH ST STE 104
VANCOUVER WA
98662-1643
US

IV. Provider business mailing address

11500 NE 119TH ST STE 104
VANCOUVER WA
98662-1643
US

V. Phone/Fax

Practice location:
  • Phone: 360-326-3396
  • Fax: 360-369-0015
Mailing address:
  • Phone: 360-326-3396
  • Fax: 360-369-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID ISAAC JOHNSON
Title or Position: CEO, CHIROPRACTOR
Credential: D.C.
Phone: 360-326-3396