=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659731974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE FORCE CHIROPRACTIC OF PUYALLUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2016
-----------------------------------------------------
Last Update Date | 02/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13333 MERIDIAN E STE H
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98373-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-200-4401
-----------------------------------------------------
Fax | 253-200-4402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13333 MERIDIAN E STE H
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98373-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-200-4401
-----------------------------------------------------
Fax | 253-200-4402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TRACY SMART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-200-4401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH80312800
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------