Healthcare Provider Details

I. General information

NPI: 1619208188
Provider Name (Legal Business Name): WESTSIDE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2010
Last Update Date: 01/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 CALIFORNIA AVE SW SUITE F
SEATTLE WA
98136-1501
US

IV. Provider business mailing address

5400 CALIFORNIA AVE SW SUITE F
SEATTLE WA
98136-1501
US

V. Phone/Fax

Practice location:
  • Phone: 206-937-8866
  • Fax: 206-937-8869
Mailing address:
  • Phone: 206-937-8866
  • Fax: 206-937-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH34316
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA20985
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARILYN KAVANAUGH
Title or Position: OWNER
Credential: DC
Phone: 206-937-8866