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General NPI Number Information
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NPI Number | 1457779738
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Entity Type | Organization
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Legal Business Name | 5E COMMUNITY CLINIC, LLC
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 5424 BALLARD AVE NW SUITE 301
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City | SEATTLE
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State | WA
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Zip | 98107-4046
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Country | US
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Telephone | 206-781-1371
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Fax | 206-781-1380
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Provider Business Mailing Address
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Address Line | 5424 BALLARD AVE NW SUITE 301
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City | SEATTLE
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State | WA
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Zip | 98107-4046
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Country | US
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Telephone | 206-781-1371
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Fax | 206-781-1380
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | MARK R TIBEAU
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Credential | EAMP, L.AC
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Telephone | 206-781-1371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | WA-585
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License Number State | WA
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