MEDICARE: JERRY M PAYNE D.C., INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH00003603	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G8851005	OTHER	WA	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	PA4216	OTHER	WA	REGENCE BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0124952	OTHER	WA	DEPT OF LABOR & INDUSTRIE

General Provider Information

NPI Number	:	1396929006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY M PAYNE D.C., INC

Provider Business Mailing Address
First Line	:	1217 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4301
Country	:	US
Telephone Number	:	360-452-3017
Fax Number	:	360-452-4100

Provider Business Practice Location Address
First Line	:	1217 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4301
Country	:	US
Telephone Number	:	360-452-3017
Fax Number	:	360-452-4100

Authorized Official
Title or Position	:	OWNER
Name	:	JERRY M PAYNE
Credential	:
Telephone Number	:	360-452-3017

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	10/17/2012

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Directions to “JERRY M PAYNE D.C., INC ” Practice Location

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