Healthcare Provider Details

I. General information

NPI: 1497914170
Provider Name (Legal Business Name): VITALITY CHIROPRACTIC CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12811 SE 38TH ST
BELLEVUE WA
98006-1326
US

IV. Provider business mailing address

12811 SE 38TH ST
BELLEVUE WA
98006-1326
US

V. Phone/Fax

Practice location:
  • Phone: 425-378-1800
  • Fax: 425-746-1587
Mailing address:
  • Phone: 425-378-1800
  • Fax: 425-746-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberMA00025081
License Number StateWA

VIII. Authorized Official

Name: MR. KENNETH HAROLD KIESWETTER II
Title or Position: MASSAGE PRACTITIONER
Credential: LMP
Phone: 425-378-1800