=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073060729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH ACUPUNCTURE AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2016
-----------------------------------------------------
Last Update Date | 09/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5108 196TH ST SW STE 208
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-6152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-586-0459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15102 61ST AVE SE
-----------------------------------------------------
City | SNOHOMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98296-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-586-0459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST
-----------------------------------------------------
Name | MR. NIMULRITH SETH
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 425-586-0459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | AC60271621
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------