Provider Demographics
NPI:1649817354
Name:KITSAP SPINE AND WELLNESS PLLC
Entity type:Organization
Organization Name:KITSAP SPINE AND WELLNESS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-377-1626
Mailing Address - Street 1:3888 NW RANDALL WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7847
Mailing Address - Country:US
Mailing Address - Phone:360-377-1626
Mailing Address - Fax:360-377-1903
Practice Address - Street 1:3888 NW RANDALL WAY STE 202
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7847
Practice Address - Country:US
Practice Address - Phone:360-377-1626
Practice Address - Fax:360-377-1903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty