=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063862316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K&K INDUSTRIES LLC DBA THE WORKSHOP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2016
-----------------------------------------------------
Last Update Date | 06/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 SUNSET AVE
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98020-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-546-7681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 SUNSET AVE
-----------------------------------------------------
City | EDMONDS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98020-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLY ENGELKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-951-0502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA60432921
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------