=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891892154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL LEE CHURCH DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1410 S MERIDIAN STE A
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-841-4425
-----------------------------------------------------
Fax | 253-445-5712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1272
-----------------------------------------------------
City | SUMNER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98390-0250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-841-4425
-----------------------------------------------------
Fax | 253-445-5712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00003323
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------