=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467542274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILLITO CHIROPRACTIC CENTER, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5511 112TH AVENUE CT E SUITE B
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-5942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-845-4655
-----------------------------------------------------
Fax | 253-845-1052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5511 112TH AVENUE CT E SUITE B
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-5942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-845-4655
-----------------------------------------------------
Fax | 253-845-1052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DERROL M. SILLITO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 253-845-4655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1192
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------