Healthcare Provider Details

I. General information

NPI: 1760755425
Provider Name (Legal Business Name): SACRED ROOT ACUPUNCTURE & NATUROPATHIC MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 MAIN ST SUITE A
EDMONDS WA
98020-3096
US

IV. Provider business mailing address

611 MAIN ST SUITE A
EDMONDS WA
98020-3096
US

V. Phone/Fax

Practice location:
  • Phone: 425-229-1070
  • Fax:
Mailing address:
  • Phone: 425-256-7798
  • Fax: 425-274-3409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number60244418
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number60515973
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberAC155797
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number#AC60244418
License Number StateWA

VIII. Authorized Official

Name: JOSHUA L GREEN
Title or Position: CO-OWNER, PRACTITIONER
Credential: LAC,
Phone: 425-256-7798