Healthcare Provider Details

I. General information

NPI: 1396154993
Provider Name (Legal Business Name): SEATAC BURIEN CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15217 1ST AVE S
BURIEN WA
98148-1009
US

IV. Provider business mailing address

3914 154TH AVE SE
BELLEVUE WA
98006-1748
US

V. Phone/Fax

Practice location:
  • Phone: 206-244-8805
  • Fax:
Mailing address:
  • Phone: 206-851-7754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH2078
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00012516
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00012587
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00018911
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60299576
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60518061
License Number StateWA

VIII. Authorized Official

Name: MR. RALPH VISCO
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 206-244-8805