Healthcare Provider Details

I. General information

NPI: 1366086530
Provider Name (Legal Business Name): QUEZADA ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28801 SE 480TH ST
ENUMCLAW WA
98022-9357
US

IV. Provider business mailing address

28801 SE 480TH ST
ENUMCLAW WA
98022-9357
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-1344
  • Fax: 360-802-2442
Mailing address:
  • Phone: 360-825-1344
  • Fax: 360-802-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. DONNA M QUEZADA
Title or Position: SECRETARY TREASURER
Credential: DC
Phone: 360-825-1344