Healthcare Provider Details

I. General information

NPI: 1407053192
Provider Name (Legal Business Name): INTEGRATED CENTER FOR OPTIMUM HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 2ND AVE STE 100
SEATTLE WA
98121
US

IV. Provider business mailing address

720 OLIVE WAY STE 900
SEATTLE WA
98101-1840
US

V. Phone/Fax

Practice location:
  • Phone: 206-624-4020
  • Fax: 206-443-3888
Mailing address:
  • Phone: 206-623-2220
  • Fax: 206-623-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00002074
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: PAUL DE BEIJL
Title or Position: OWNER
Credential: L.AC, PT
Phone: 206-623-2220