Healthcare Provider Details

I. General information

NPI: 1477614311
Provider Name (Legal Business Name): LIFE CHANGES HEALTH CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 HEWITT AVE
EVERETT WA
98201-3820
US

IV. Provider business mailing address

PO BOX 12608
MILL CREEK WA
98082-0608
US

V. Phone/Fax

Practice location:
  • Phone: 425-252-6484
  • Fax:
Mailing address:
  • Phone: 425-252-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT00000478
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30006112
License Number StateWA

VIII. Authorized Official

Name: DR. LYNDON C CAPON
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD, ARNP, ND
Phone: 425-750-0881