Healthcare Provider Details

I. General information

NPI: 1144749656
Provider Name (Legal Business Name): NATURAL LIFE INTEGRATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 23RD AVE SE
PUYALLUP WA
98372-4501
US

IV. Provider business mailing address

102 23RD AVE SE
PUYALLUP WA
98372-4501
US

V. Phone/Fax

Practice location:
  • Phone: 253-268-2170
  • Fax: 253-268-0658
Mailing address:
  • Phone: 253-268-2170
  • Fax: 253-268-0658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60524427
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberNT60524427
License Number StateWA

VIII. Authorized Official

Name: DR. LAURA ELAYNE FIRETAG
Title or Position: MEDICAL DIRECTOR, TREASURER
Credential: ND
Phone: 843-209-3966