MEDICARE: CLASSIC CHIROPRACTIC P.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHOOOO2656	WA

General Provider Information

NPI Number	:	1154511806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLASSIC CHIROPRACTIC P.S.

Provider Business Mailing Address
First Line	:	P.O.BOX 3082
Second Line	:
City	:	YELM
State	:	WA
Zip	:	98597
Country	:	US
Telephone Number	:	360-400-2225
Fax Number	:	360-400-2282

Provider Business Practice Location Address
First Line	:	35025 90TH AVE. S.
Second Line	:	UNIT 6
City	:	ROY
State	:	WA
Zip	:	98580
Country	:	US
Telephone Number	:	360-400-2225
Fax Number	:	360-400-2282

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARVIN ISAMU KUNIKIYO
Credential	:	D.C.
Telephone Number	:	360-458-3847

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	11/04/2010

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