Healthcare Provider Details

I. General information

NPI: 1346650330
Provider Name (Legal Business Name): SKY CHIROPRACTIC AND MASSAGE PS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 RAINIER AVE S STE 3
RENTON WA
98057-3200
US

IV. Provider business mailing address

710A S 38TH ST
TACOMA WA
98418-6718
US

V. Phone/Fax

Practice location:
  • Phone: 425-255-5886
  • Fax:
Mailing address:
  • Phone: 253-830-6899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 00003526
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60769473
License Number StateWA

VIII. Authorized Official

Name: DR. SKY BOULOM
Title or Position: PRESIDENT
Credential: DC
Phone: 425-773-8553