Healthcare Provider Details

I. General information

NPI: 1154734531
Provider Name (Legal Business Name): EARTH STAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 NE 113TH ST
SEATTLE WA
98125-6744
US

IV. Provider business mailing address

2319 N 45TH ST SUITE 211
SEATTLE WA
98103-6982
US

V. Phone/Fax

Practice location:
  • Phone: 206-380-0368
  • Fax:
Mailing address:
  • Phone: 206-380-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60083354
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00005295
License Number StateWA

VIII. Authorized Official

Name: EVAN KIMBLE
Title or Position: OWNER
Credential:
Phone: 206-380-0368