Healthcare Provider Details

I. General information

NPI: 1811323801
Provider Name (Legal Business Name): SUNRISE MOONSHADOW COULTER LMT, LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 N 5TH AVE
SEQUIM WA
98382-3079
US

IV. Provider business mailing address

PO BOX 853
PORT TOWNSEND WA
98368-0853
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-7911
  • Fax:
Mailing address:
  • Phone: 541-306-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18466
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60408973
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: