Provider Demographics
NPI:1346650330
Name:SKY CHIROPRACTIC AND MASSAGE PS INC
Entity Type:Organization
Organization Name:SKY CHIROPRACTIC AND MASSAGE PS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-773-8553
Mailing Address - Street 1:710A S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6718
Mailing Address - Country:US
Mailing Address - Phone:253-830-6899
Mailing Address - Fax:
Practice Address - Street 1:757 RAINIER AVE S STE 3
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3200
Practice Address - Country:US
Practice Address - Phone:425-255-5886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH 00003526111N00000X
WAMA60769473225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty