=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013200492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETES PERFORMANCE CENTER PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2011
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4755 FAUNTLEROY WAY SW STE 120
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98116-4669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-946-1323
-----------------------------------------------------
Fax | 206-926-7908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7116 WOODLAWN AVE NE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98115-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-522-6240
-----------------------------------------------------
Fax | 206-926-7899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL D BOURBONNAIS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 206-522-6240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00003244
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | CH00034592
-----------------------------------------------------
License Number State |
-----------------------------------------------------