Provider Demographics
NPI:1861031684
Name:MIDWAY HEALTHCARE THERAPEUTICS LLC
Entity Type:Organization
Organization Name:MIDWAY HEALTHCARE THERAPEUTICS LLC
Other - Org Name:FAIRWOOD CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TALLON
Authorized Official - Middle Name:
Authorized Official - Last Name:NISHIHATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-824-9500
Mailing Address - Street 1:14410 SE PETROVITSKY RD STE 109
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8900
Mailing Address - Country:US
Mailing Address - Phone:425-226-1856
Mailing Address - Fax:425-226-0231
Practice Address - Street 1:14410 SE PETROVITSKY RD STE 109
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-226-1856
Practice Address - Fax:425-226-0231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY HEALTHCARE THERAPEUTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-26
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty