Provider Demographics
NPI:1780234872
Name:KATHIRESON, SULAKSHANDAN (DC)
Entity type:Individual
Prefix:
First Name:SULAKSHANDAN
Middle Name:
Last Name:KATHIRESON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:KATHIRESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:12901 SE KENT KANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7939
Mailing Address - Country:US
Mailing Address - Phone:253-630-1575
Mailing Address - Fax:253-630-4650
Practice Address - Street 1:1040 UNIVERSITY AVE # B210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7328
Practice Address - Country:US
Practice Address - Phone:619-230-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60981294111N00000X
CA34704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor