=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760734172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN BUSH DAOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 10/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1818 E MERCER ST STE 100
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98112-4687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-466-2329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5729 65TH AVE NE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98105-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-691-3553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 60086618
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------