Healthcare Provider Details

I. General information

NPI: 1689198202
Provider Name (Legal Business Name): IDEAL MOTION SPINE AND SPORTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 5TH AVE N STE A
SEATTLE WA
98109-4241
US

IV. Provider business mailing address

621 5TH AVE N STE A
SEATTLE WA
98109-4241
US

V. Phone/Fax

Practice location:
  • Phone: 206-858-6667
  • Fax:
Mailing address:
  • Phone: 206-858-6667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH60271312
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60293770
License Number StateWA

VIII. Authorized Official

Name: ZACHARY ZUGSCHWERDT
Title or Position: OWNER
Credential: D.C., CCSP
Phone: 206-858-6667