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General NPI Number Information
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NPI Number | 1699206821
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Entity Type | Organization
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Legal Business Name | BLUE TUSK ACUPUNCTURE CLINIC, LLC
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Dates
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Enumeration Date | 03/21/2017
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Last Update Date | 04/17/2020
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Provider Practice Location Address
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Address Line | 5903 244TH ST SW STE E
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City | MOUNTLAKE TERRACE
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State | WA
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Zip | 98043-5451
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Country | US
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Telephone | 360-218-4602
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Fax |
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Provider Business Mailing Address
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Address Line | 5903 244TH ST SW STE E
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City | MOUNTLAKE TERRACE
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State | WA
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Zip | 98043-5451
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Country | US
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Telephone | 360-218-4602
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Fax |
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Authorized Official
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Title or Position | OWNER/ ACUPUNCTURIST
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Name | ANDREJ PRADO NICKEL
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Credential | L.AC., EAMP
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Telephone | 360-218-4602
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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 | AC60616546
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License Number State | WA
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