Provider Demographics
NPI:1275899460
Name:FORMO ENTERPRISES, INC
Entity Type:Organization
Organization Name:FORMO ENTERPRISES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:FORMO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-483-2320
Mailing Address - Street 1:17401 135TH AVE NE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-6825
Mailing Address - Country:US
Mailing Address - Phone:425-483-2320
Mailing Address - Fax:425-424-3256
Practice Address - Street 1:17401 135TH AVE NE
Practice Address - Street 2:SUITE #4
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-6825
Practice Address - Country:US
Practice Address - Phone:425-483-2320
Practice Address - Fax:425-424-3256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBERLY FORMO, DC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034796111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8868363Medicare UPIN