=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174821482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODYTITE CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2011
-----------------------------------------------------
Last Update Date | 11/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1823 115TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-591-9910
-----------------------------------------------------
Fax | 844-927-4477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1823 115TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-591-9910
-----------------------------------------------------
Fax | 844-927-4477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. CHERYLENA SIMMONDS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 425-591-9910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | CH00034551
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------