Provider Demographics
NPI:1871766154
Name:BURL PETTIBON
Entity type:Organization
Organization Name:BURL PETTIBON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-858-2474
Mailing Address - Street 1:7108 PIONEER WAY
Mailing Address - Street 2:STE A
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1178
Mailing Address - Country:US
Mailing Address - Phone:253-858-2474
Mailing Address - Fax:253-858-6511
Practice Address - Street 1:7108 PIONEER WAY
Practice Address - Street 2:STE A
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1178
Practice Address - Country:US
Practice Address - Phone:253-858-2474
Practice Address - Fax:253-858-6511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00000551111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8801170Medicare PIN