Healthcare Provider Details

I. General information

NPI: 1174821482
Provider Name (Legal Business Name): BODYTITE CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 11/01/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 115TH AVE NE
BELLEVUE WA
98004-3002
US

IV. Provider business mailing address

1823 115TH AVE NE
BELLEVUE WA
98004-3002
US

V. Phone/Fax

Practice location:
  • Phone: 425-591-9910
  • Fax: 844-927-4477
Mailing address:
  • Phone: 425-591-9910
  • Fax: 844-927-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberCH00034551
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHERYLENA SIMMONDS
Title or Position: PHYSICIAN
Credential: D.C.
Phone: 425-591-9910