=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821616384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE GENTLE ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2020
-----------------------------------------------------
Last Update Date | 07/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1427 228TH ST SE STE D1
-----------------------------------------------------
City | BOTHELL
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98021-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-835-6299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14120 NE 183RD ST # 1-410
-----------------------------------------------------
City | WOODINVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98072-7070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-638-9098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF THE COMPANY
-----------------------------------------------------
Name | MRS. ROKHSAREH MOHAMMADI
-----------------------------------------------------
Credential | ACUPUNCTURIST
-----------------------------------------------------
Telephone | 425-638-9098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------