=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386189983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUILIBRIUM NATURAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2017
-----------------------------------------------------
Last Update Date | 01/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9481 BAYSHORE DR NW STE. 103A
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-698-4141
-----------------------------------------------------
Fax | 877-343-5484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9481 BAYSHORE DR NW STE. 103A
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-698-4141
-----------------------------------------------------
Fax | 877-343-5484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PHYSICIAN/OWNER/OPERATOR
-----------------------------------------------------
Name | DR. CY ROBERT FISHER
-----------------------------------------------------
Credential | N.D.
-----------------------------------------------------
Telephone | 360-698-4141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | NT 60508818
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------