Provider Demographics
NPI:1255838298
Name:MINDBODY MEDICINE PC
Entity Type:Organization
Organization Name:MINDBODY MEDICINE PC
Other - Org Name:WEDGWOOD CENTER FOR NATURAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CHEVIGNY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-523-9000
Mailing Address - Street 1:2028 43RD AVE E APT 2-4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-2758
Mailing Address - Country:US
Mailing Address - Phone:206-660-6085
Mailing Address - Fax:
Practice Address - Street 1:2705 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-7129
Practice Address - Country:US
Practice Address - Phone:206-523-9000
Practice Address - Fax:206-523-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60522163111N00000X, 111NR0400X, 111NS0005X
171100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1669860052OtherNPI