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General NPI Number Information
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NPI Number | 1104066836
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Entity Type | Organization
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Legal Business Name | EMERALD VINE PLLC
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Dates
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Enumeration Date | 02/20/2009
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Last Update Date | 02/20/2009
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Provider Practice Location Address
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Address Line | 142 NW CANAL ST
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City | SEATTLE
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State | WA
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Zip | 98107-4933
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Country | US
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Telephone | 206-347-0777
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Fax | 888-254-3281
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Provider Business Mailing Address
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Address Line | 142 NW CANAL ST
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City | SEATTLE
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State | WA
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Zip | 98107-4933
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Country | US
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Telephone | 206-347-0777
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Fax | 888-254-3281
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Authorized Official
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Title or Position | OWNER
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Name | MS. SHAINA MARIKO AKIDAU
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Credential | LMP
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Telephone | 206-347-0777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172M00000X
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Taxonomy Name | Mechanotherapist
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License Number | MA00025243
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License Number State | WA
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