=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902842958
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARRY A QUAM DC PS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 02/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25012 104TH AVE SE SUITE E
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98030-2821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-854-1233
-----------------------------------------------------
Fax | 253-854-1297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25012 - 104TH AVE SE SUITE E
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98030-2821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-854-1233
-----------------------------------------------------
Fax | 253-854-1297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00001274
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------