Healthcare Provider Details

I. General information

NPI: 1558586487
Provider Name (Legal Business Name): FAIRWOOD CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14410 SE PETROVITSKY RD STE 109
RENTON WA
98058-8900
US

IV. Provider business mailing address

14410 SE PETROVITSKY RD STE 109
RENTON WA
98058-8900
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-1856
  • Fax: 425-226-0231
Mailing address:
  • Phone: 425-226-1856
  • Fax: 425-226-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00001828
License Number StateWA

VIII. Authorized Official

Name: STEVEN THOMAS RYAN
Title or Position: OWNER
Credential: DC
Phone: 425-226-1856