Healthcare Provider Details

I. General information

NPI: 1114431079
Provider Name (Legal Business Name): MIRACLE ISLAND PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 10/11/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7605 SE 27TH ST STE 103
MERCER ISLAND WA
98040-2852
US

IV. Provider business mailing address

7605 SE 27TH ST STE 103
MERCER ISLAND WA
98040-2852
US

V. Phone/Fax

Practice location:
  • Phone: 206-519-9039
  • Fax:
Mailing address:
  • Phone: 206-519-9039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60696857
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60654589
License Number StateWA

VIII. Authorized Official

Name: HAIMING SHI
Title or Position: CEO
Credential:
Phone: 206-519-9039