Basic Information
| Provider Information | |||||||||
| NPI: | 1619268802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRUM HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15811 AMBAUM BLVD SW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428211 | ||||||||
| FaxNumber: | 2062420162 | ||||||||
| Practice Location | |||||||||
| Address1: | 15811 AMBAUM BLVD SW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428211 | ||||||||
| FaxNumber: | 2062420162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIROPRACTOR | ||||||||
| AuthorizedOfficialTelephone: | 2062428211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | CH00034837 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0274108 | 01 | WA | LABOR & INDUSTRIES | OTHER |