MEDICARE: GREEN LAKE CHIROPRACTIC & NUTRITIONAL HEALING LLC

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

General Provider Information

NPI Number	:	1649440918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN LAKE CHIROPRACTIC & NUTRITIONAL HEALING LLC

Provider Business Mailing Address
First Line	:	1408 N 80TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-4421
Country	:	US
Telephone Number	:	206-523-0121
Fax Number	:	206-523-0341

Provider Business Practice Location Address
First Line	:	1408 N 80TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-4421
Country	:	US
Telephone Number	:	206-523-0121
Fax Number	:	206-523-0341

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEVEN POLENZ
Credential	:	DC
Telephone Number	:	206-523-0121

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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