Healthcare Provider Details

I. General information

NPI: 1255838298
Provider Name (Legal Business Name): MINDBODY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 NE 65TH ST
SEATTLE WA
98115-7129
US

IV. Provider business mailing address

2028 43RD AVE E APT 2-4
SEATTLE WA
98112-2758
US

V. Phone/Fax

Practice location:
  • Phone: 206-523-9000
  • Fax: 206-523-5566
Mailing address:
  • Phone: 206-660-6085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH60522163
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCH60522163
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60522163
License Number StateWA

VIII. Authorized Official

Name: DR. JOHN RICHARD CHEVIGNY
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 206-523-9000