Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 001920 | WA |
NPI | 1003917329 |
---|---|
Provider Name | Dr. John Bruce Permen |
First Address | Lynden, WA 98264-9405 |
Second Address | Lynden, WA 98264-9464 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 26/09/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6020 | DEPT. OF LABOR & INDUST (01) | WA |
653559 | ACN (01) | WA |
G8806685 | MEDICARE ID-TYPE UNSPECIFIED (01) | WA |