Provider Demographics
NPI:1710119102
Name:MKG FULL MOON INC
Entity Type:Organization
Organization Name:MKG FULL MOON INC
Other - Org Name:CORE CHIROPRACTIC & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUQUICCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-708-7172
Mailing Address - Street 1:2611 NE 125TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-4373
Mailing Address - Country:US
Mailing Address - Phone:206-708-7172
Mailing Address - Fax:206-913-2568
Practice Address - Street 1:2611 NE 125TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-4373
Practice Address - Country:US
Practice Address - Phone:206-708-7172
Practice Address - Fax:206-913-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty