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General NPI Number Information
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NPI Number | 1659741858
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Entity Type | Organization
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Legal Business Name | CANYON CROSSING CHIROPRACTIC PS
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Dates
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Enumeration Date | 09/30/2015
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Last Update Date | 05/13/2019
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Provider Practice Location Address
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Address Line | 5610 176TH ST E D105
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City | PUYALLUP
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State | WA
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Zip | 98375-9305
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Country | US
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Telephone | 847-208-0973
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Fax |
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Provider Business Mailing Address
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Address Line | 5610 176TH ST E D105
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City | PUYALLUP
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State | WA
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Zip | 98375-9305
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Country | US
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Telephone | 847-208-0973
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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. JACOB BROWN
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Credential | D.C
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Telephone | 847-208-0973
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | CH 60520744
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License Number State | WA
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