Healthcare Provider Details

I. General information

NPI: 1104157858
Provider Name (Legal Business Name): RISING TIDE NATURAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 30TH ST
BOULDER CO
80301-1103
US

IV. Provider business mailing address

4985 TWIN LAKES RD APT 87
BOULDER CO
80301-3894
US

V. Phone/Fax

Practice location:
  • Phone: 303-501-0819
  • Fax:
Mailing address:
  • Phone: 303-501-0819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1127
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNP227
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State

VIII. Authorized Official

Name: DR. LIAM MCCLINTOCK
Title or Position: PRESIDENT
Credential: ND, LAC
Phone: 207-865-1222