Basic Information
| Provider Information | |||||||||
| NPI: | 1780812917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDAURI | ||||||||
| FirstName: | QUINCY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 432 MAIN AVE N | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980458237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258020400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 SW 160TH ST | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173C00000X | MA60076727 | WA | N | Other Service Providers | Reflexologist | 225700000X | MA60076727 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.