Healthcare Provider Details

I. General information

NPI: 1063878684
Provider Name (Legal Business Name): PRIMAVITA FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15446 BEL RED RD STE B15
REDMOND WA
98052-5507
US

IV. Provider business mailing address

15446 BEL RED RD STE B15
REDMOND WA
98052-5507
US

V. Phone/Fax

Practice location:
  • Phone: 425-273-0741
  • Fax: 844-218-1125
Mailing address:
  • Phone: 425-273-0741
  • Fax: 844-218-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60071802
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60071822
License Number StateWA

VIII. Authorized Official

Name: MS. LORINA SHINSATO
Title or Position: OWNER
Credential: N.D., EAMP
Phone: 425-273-0741