Healthcare Provider Details

I. General information

NPI: 1770900847
Provider Name (Legal Business Name): VELO SPORTS REHAB CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 116TH AVE NE SUITE 100
BELLEVUE WA
98004-3097
US

IV. Provider business mailing address

1940 116TH AVE NE SUITE 100
BELLEVUE WA
98004-3097
US

V. Phone/Fax

Practice location:
  • Phone: 425-590-9208
  • Fax:
Mailing address:
  • Phone: 425-590-9208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH00034592
License Number StateWA

VIII. Authorized Official

Name: DR. ERIC DEROCHE
Title or Position: PRESIDENT
Credential: DC
Phone: 425-590-9208