Healthcare Provider Details

I. General information

NPI: 1841180510
Provider Name (Legal Business Name): KEVIN PHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SW 41ST ST
RENTON WA
98057-4926
US

IV. Provider business mailing address

435 SW 41ST ST
RENTON WA
98057-4926
US

V. Phone/Fax

Practice location:
  • Phone: 425-728-4822
  • Fax:
Mailing address:
  • Phone: 425-728-4822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR.CH.70123429
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: