Sam L Pettibon, D.O.

Primary specialty

Rehabilitation ChiropractorTaxonomy code 111NR0400X

License

2174 Issued in WA

Practice address

30804 Pacific Hwy S
Federal Way, WA 98003-4902

Phone

(253) 839-5644

Fax

(253) 839-2625

NPI assigned

Apr 17, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in WA

Enrollment records 1

Specialty

Chiropractic

Education

Life Chiropractic College - West, 1985

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pettibon Chiropractic Clinic of Federal Way Inc.

  • Chiropractor
  • Federal Way, WA
  • NPI 1134487846
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176768000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1335916800000",
    "number": "1386860492",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "30804 PACIFIC HWY S",
            "city": "FEDERAL WAY",
            "state": "WA",
            "postal_code": "980034902",
            "telephone_number": "253-839-5644",
            "fax_number": "253-839-2625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30804 PACIFIC HWY S",
            "city": "FEDERAL WAY",
            "state": "WA",
            "postal_code": "980034902",
            "telephone_number": "253-839-5644",
            "fax_number": "253-839-2625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTIBON",
        "first_name": "SAM",
        "middle_name": "L",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-04-17",
        "last_updated": "2012-05-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "111NR0400X",
            "taxonomy_group": "",
            "desc": "Chiropractor, Rehabilitation",
            "state": "WA",
            "license": "2174",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE INSURANCE PROVIDE",
            "identifier": "PE5678",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2007078",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L & I PROVIDER",
            "identifier": "73321",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Shon Peterson
• Eileen Gwendolyn Petrie, CDPT
• Todd Petrowski
• Hanna Kirsti Petry, CNM
• Pettibon Chiropractic Clinic of Federal Way Inc.
• Anne M Pettinger, ARNP
• An Pham, O.D.
• Nhat Pham, MD
• Thanh V Pham, MD
• Minh Quang Phan

• Rehabilitation Chiropractor in Federal Way, WA
• Providers in Federal Way, WA by specialty
• Rehabilitation Chiropractor in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 2, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.