Healthcare Provider Details

I. General information

NPI: 1326682741
Provider Name (Legal Business Name): JORDAN THOMAS KALIL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 SE 38TH ST STE 305B
BELLEVUE WA
98006-1763
US

IV. Provider business mailing address

2233 74TH AVE SE
MERCER ISLAND WA
98040-2328
US

V. Phone/Fax

Practice location:
  • Phone: 425-289-0092
  • Fax: 425-289-0095
Mailing address:
  • Phone: 206-949-0276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number60985695
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: