Healthcare Provider Details

I. General information

NPI: 1164778221
Provider Name (Legal Business Name): MAYA WHOLE HEALTH AT SOUTHPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 LAKE WASHINGTON BLVD N SUITE 3
RENTON WA
98056-0703
US

IV. Provider business mailing address

1322 LAKE WASHINGTON BLVD N SUITE 3
RENTON WA
98056-0703
US

V. Phone/Fax

Practice location:
  • Phone: 425-271-0200
  • Fax: 206-309-3383
Mailing address:
  • Phone: 425-271-0200
  • Fax: 206-309-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MS. WENDY JEAN RAY
Title or Position: STUDIO COORDINATOR
Credential:
Phone: 425-271-0200