Individual
SAM L PETTIBON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
30804 PACIFIC HWY S, FEDERAL WAY, WA 98003-4902
(253) 839-5644
(253) 839-2625
Mailing address
30804 PACIFIC HWY S, FEDERAL WAY, WA 98003-4902
(253) 839-5644
(253) 839-2625
Taxonomy
Speciality
Code
Description
License number
State
111NR0400X
Rehabilitation Chiropractor
Primary
2174
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2007078
—
WA
01
—
73321
L & I PROVIDER
WA
01
—
PE5678
REGENCE INSURANCE PROVIDE
WA
Enumeration date
04/17/2007
Last updated
05/02/2012
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