Healthcare Provider Details

I. General information

NPI: 1487426110
Provider Name (Legal Business Name): BODLE CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22312 MARINE VIEW DR S
DES MOINES WA
98198-6832
US

IV. Provider business mailing address

22312 MARINE VIEW DR S
DES MOINES WA
98198-6832
US

V. Phone/Fax

Practice location:
  • Phone: 206-824-8464
  • Fax: 206-824-8470
Mailing address:
  • Phone: 206-824-8464
  • Fax: 206-824-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. SARINA BALLARD
Title or Position: EXECUTIVE ADMINISTRATIVE ASSISTANT
Credential:
Phone: 206-824-8464