Basic Information
| Provider Information | |||||||||
| NPI: | 1417099243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOREM | ||||||||
| FirstName: | MONTI | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 140TH AVE NE | ||||||||
| Address2: | STE D | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256880223 | ||||||||
| FaxNumber: | 4256880323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 140TH AVE NE | ||||||||
| Address2: | STE D | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256880223 | ||||||||
| FaxNumber: | 4256880323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH00034488 | WA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 2031284 | 05 | WA | MEDICAID |