Provider Demographics
NPI:1780812917
Name:VIDAURI, QUINCY (LMP)
Entity type:Individual
Prefix:MS
First Name:QUINCY
Middle Name:
Last Name:VIDAURI
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 MAIN AVE N
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-8237
Mailing Address - Country:US
Mailing Address - Phone:425-802-0400
Mailing Address - Fax:
Practice Address - Street 1:120 SW 160TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3025
Practice Address - Country:US
Practice Address - Phone:206-242-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60076727173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist