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General NPI Number Information
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NPI Number | 1710032057
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Entity Type | Organization
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Legal Business Name | ADVANCED CHIROPRACTIC CENTRE CORP
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 705 SE PARK CREST AVE., STE A120
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City | VANCOUVER
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State | WA
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Zip | 98683-1303
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Country | US
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Telephone | 360-892-3654
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Fax | 360-892-3692
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Provider Business Mailing Address
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Address Line | 705 SE PARK CREST AVE., STE A120
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City | VANCOUVER
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State | WA
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Zip | 98683-1303
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Country | US
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Telephone | 360-892-3654
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Fax | 360-892-3692
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Authorized Official
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Title or Position | OWNER
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Name | LARRY LEE WASILENKOFF
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Credential | D.C
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Telephone | 360-892-3654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | CH00003418
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License Number State | WA
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