Provider Demographics
NPI:1013200492
Name:ATHLETE'S PERFORMANCE CENTER
Entity Type:Organization
Organization Name:ATHLETE'S PERFORMANCE CENTER
Other - Org Name:KINETIC SPORTS REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOURBONNAIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-547-0707
Mailing Address - Street 1:701 N 36TH ST
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8868
Mailing Address - Country:US
Mailing Address - Phone:206-547-0707
Mailing Address - Fax:206-420-5386
Practice Address - Street 1:701 N 36TH ST
Practice Address - Street 2:SUITE 430
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8868
Practice Address - Country:US
Practice Address - Phone:206-547-0707
Practice Address - Fax:206-420-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003244111N00000X
CH00034592111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty