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General NPI Number Information
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NPI Number | 1043695547
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Entity Type | Organization
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Legal Business Name | MAGNOLIA NATUROPATHIC MEDICINE, LLC
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Dates
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Enumeration Date | 07/25/2015
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Last Update Date | 07/25/2015
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Provider Practice Location Address
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Address Line | 803 39TH AVE SW STE F
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City | PUYALLUP
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State | WA
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Zip | 98373-3692
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Country | US
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Telephone | 253-848-1055
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Fax | 253-848-5533
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Provider Business Mailing Address
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Address Line | 803 39TH AVE SW STE F
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City | PUYALLUP
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State | WA
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Zip | 98373-3692
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Country | US
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Telephone | 253-848-1055
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Fax | 253-848-5533
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Authorized Official
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Title or Position | NATUROPATHIC PHYSICIAN
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Name | DR. LAURA ELAYNE FIRETAG
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Credential | ND
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Telephone | 843-209-3966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | NT60524427
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License Number State | WA
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