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General NPI Number Information
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NPI Number | 1760945968
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Entity Type | Organization
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Legal Business Name | LIVING WELL KENT COLLABORATIVE
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Dates
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Enumeration Date | 04/13/2019
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Last Update Date | 04/13/2019
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Provider Practice Location Address
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Address Line | 515 W HARRISON ST STE 208
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City | KENT
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State | WA
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Zip | 98032-4403
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Country | US
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Telephone | 253-457-2964
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Fax |
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Provider Business Mailing Address
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Address Line | 10605 SE 240TH ST # 232
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City | KENT
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State | WA
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Zip | 98031-4903
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Country | US
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Telephone | 253-457-2964
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SHAMSO ISSAK
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Credential |
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Telephone | 253-457-2964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State |
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