=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134514656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDENDORF CHIROPRACTIC PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2015
-----------------------------------------------------
Last Update Date | 04/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4255 SE MILE HILL DR # 101
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-3920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-871-5200
-----------------------------------------------------
Fax | 360-871-5350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 525
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-0525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-871-5200
-----------------------------------------------------
Fax | 360-817-5350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. REBEKAH ROSE LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-871-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------