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General NPI Number Information
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NPI Number | 1447494984
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Entity Type | Organization
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Legal Business Name | BAYSIDE CHIROPRACTIC, PLLC
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Dates
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Enumeration Date | 04/28/2009
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Last Update Date | 01/14/2023
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Provider Practice Location Address
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Address Line | 7307 40TH ST W STE B
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98466-4385
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Country | US
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Telephone | 253-753-6204
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Fax |
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Provider Business Mailing Address
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Address Line | 4250 ALTURUS ST W
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98466-6612
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Country | US
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Telephone | 253-753-8620
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHANE D BOUCHER
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Credential | D.C.
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Telephone | 253-753-6204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 11178
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License Number State | TX
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