Healthcare Provider Details

I. General information

NPI: 1174822159
Provider Name (Legal Business Name): PACIFIC RIM HEADACHE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SEAFARERS WAY STE 201 B
ANACORTES WA
98221-2257
US

IV. Provider business mailing address

715 SEAFARERS WAY STE 201 B
ANACORTES WA
98221-2257
US

V. Phone/Fax

Practice location:
  • Phone: 360-588-1460
  • Fax: 360-588-1473
Mailing address:
  • Phone: 360-588-1460
  • Fax: 360-588-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004470
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00009893
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00017410
License Number StateWA

VIII. Authorized Official

Name: JOHNNY MICHAEL JONES
Title or Position: OWNER
Credential: MPAS-C
Phone: 360-588-1460