Provider Demographics
NPI:1871256180
Name:PRO-FORM CHIROPRACTIC AND SPORTS INJURY, PLLC
Entity Type:Organization
Organization Name:PRO-FORM CHIROPRACTIC AND SPORTS INJURY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRINI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-312-3894
Mailing Address - Street 1:5534 84TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-8509
Mailing Address - Country:US
Mailing Address - Phone:203-312-3894
Mailing Address - Fax:
Practice Address - Street 1:4500 9TH AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4762
Practice Address - Country:US
Practice Address - Phone:203-312-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty