Provider Demographics
NPI:1598041139
Name:SKY CHIROPRACTIC BELLEVUE PS INC
Entity Type:Organization
Organization Name:SKY CHIROPRACTIC BELLEVUE PS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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 1:15608 18TH PL W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-8800
Mailing Address - Country:US
Mailing Address - Phone:425-773-8553
Mailing Address - Fax:
Practice Address - Street 1:12505 BEL RED RD STE 107
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2510
Practice Address - Country:US
Practice Address - Phone:425-773-8553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty