Healthcare Provider Details

I. General information

NPI: 1922846070
Provider Name (Legal Business Name): AUSTIN FOTHERGILL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 BELLEVUE WAY NE STE 200
BELLEVUE WA
98004-4295
US

IV. Provider business mailing address

15200 103RD AVE NE
BOTHELL WA
98011-7232
US

V. Phone/Fax

Practice location:
  • Phone: 425-753-2235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIR.CH.61557755
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: