Provider Demographics
NPI:1033423942
Name:NACKVISETH, VIXAI (LMP)
Entity Type:Individual
Prefix:
First Name:VIXAI
Middle Name:
Last Name:NACKVISETH
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23925 225TH WAY SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5233
Mailing Address - Country:US
Mailing Address - Phone:425-433-0123
Mailing Address - Fax:425-433-0733
Practice Address - Street 1:17307 SE 272ND ST
Practice Address - Street 2:SUITE 126
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-5304
Practice Address - Country:US
Practice Address - Phone:253-639-2266
Practice Address - Fax:253-639-8464
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist