Healthcare Provider Details

I. General information

NPI: 1760945968
Provider Name (Legal Business Name): LIVING WELL KENT COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2019
Last Update Date: 04/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W HARRISON ST STE 208
KENT WA
98032-4403
US

IV. Provider business mailing address

10605 SE 240TH ST # 232
KENT WA
98031-4903
US

V. Phone/Fax

Practice location:
  • Phone: 253-457-2964
  • Fax:
Mailing address:
  • Phone: 253-457-2964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: SHAMSO ISSAK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 253-457-2964