Healthcare Provider Details

I. General information

NPI: 1053656827
Provider Name (Legal Business Name): BERT SAGARDIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10117 MAIN ST
BOTHELL WA
98011-3425
US

IV. Provider business mailing address

2525 NE 125TH ST
SEATTLE WA
98125-4248
US

V. Phone/Fax

Practice location:
  • Phone: 425-806-5525
  • Fax:
Mailing address:
  • Phone: 206-819-7281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60311766
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: