Healthcare Provider Details

I. General information

NPI: 1063822690
Provider Name (Legal Business Name): LIVING WELL CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 E YELM AVE # C101
YELM WA
98597-8663
US

IV. Provider business mailing address

1412 E YELM AVE # C101
YELM WA
98597-8663
US

V. Phone/Fax

Practice location:
  • Phone: 360-458-7533
  • Fax:
Mailing address:
  • Phone: 360-458-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00025252
License Number StateWA

VIII. Authorized Official

Name: CRYSTAL GOMEZ
Title or Position: LMP
Credential:
Phone: 360-458-7533