Healthcare Provider Details

I. General information

NPI: 1306208830
Provider Name (Legal Business Name): LAKE FOREST PARK ACUPUNCTURE AND MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18724 35TH AVE NE
LAKE FOREST PARK WA
98155-2602
US

IV. Provider business mailing address

18724 35TH AVE NE
LAKE FOREST PARK WA
98155-2602
US

V. Phone/Fax

Practice location:
  • Phone: 206-962-7620
  • Fax:
Mailing address:
  • Phone: 206-962-7620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60525308
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60228942
License Number StateWA

VIII. Authorized Official

Name: KIERAN MCMANIMON
Title or Position: OWNER/PARTNER/MASSAGE THERAPIST
Credential: LMP
Phone: 206-962-7620