Healthcare Provider Details

I. General information

NPI: 1841112323
Provider Name (Legal Business Name): LAKE LIFE ACUPUNCTURE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN ST
SANDPOINT ID
83864-1435
US

IV. Provider business mailing address

200 MAIN ST
SANDPOINT ID
83864-1435
US

V. Phone/Fax

Practice location:
  • Phone: 208-264-0644
  • Fax:
Mailing address:
  • Phone: 208-264-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAMIE DAVIS
Title or Position: OWNER
Credential: DAOM
Phone: 206-858-1543