Healthcare Provider Details

I. General information

NPI: 1710119102
Provider Name (Legal Business Name): MKG FULL MOON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 NE 125TH ST SUITE 240
SEATTLE WA
98125-4373
US

IV. Provider business mailing address

2611 NE 125TH ST SUITE 240
SEATTLE WA
98125-4373
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-7172
  • Fax: 206-913-2568
Mailing address:
  • Phone: 206-708-7172
  • Fax: 206-913-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00003354
License Number StateWA

VIII. Authorized Official

Name: DR. DANIEL BUQUICCHIO
Title or Position: CEO
Credential: D.C.
Phone: 206-708-7172