Healthcare Provider Details

I. General information

NPI: 1225215643
Provider Name (Legal Business Name): MAYA VAJRA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 114TH AVE SE STE 105
BELLEVUE WA
98004-6958
US

IV. Provider business mailing address

513 NW BRIGHT ST STE B
SEATTLE WA
98107-4450
US

V. Phone/Fax

Practice location:
  • Phone: 206-300-1530
  • Fax:
Mailing address:
  • Phone: 206-300-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00001993
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: