=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760378855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAVERIK SPORTS REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2025
-----------------------------------------------------
Last Update Date | 06/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 AUBURN WAY N
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98002-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-631-0231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2705 AUBURN WAY N
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98002-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-631-0231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN PARHAM
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 206-631-0231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------