Provider Demographics
NPI:1548433683
Name:BAYSHORE CHIROPRACTIC, PS
Entity type:Organization
Organization Name:BAYSHORE CHIROPRACTIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KEITH-MADEIROS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-675-1066
Mailing Address - Street 1:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-1706
Mailing Address - Country:US
Mailing Address - Phone:360-675-1066
Mailing Address - Fax:360-679-2278
Practice Address - Street 1:840 SE BAYSHORE DR STE 101
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4062
Practice Address - Country:US
Practice Address - Phone:360-675-1066
Practice Address - Fax:360-679-2278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB04828Medicare UPIN