Healthcare Provider Details

I. General information

NPI: 1861031684
Provider Name (Legal Business Name): MIDWAY HEALTHCARE THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
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 TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. TALLON NISHIHATA
Title or Position: GENERAL OPERATIONS
Credential:
Phone: 206-824-9500