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General NPI Number Information
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NPI Number | 1831479724
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Entity Type | Organization
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Legal Business Name | WHITE WILLOW ROAD HEALING CENTER, LLC
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Dates
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Enumeration Date | 08/23/2011
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Last Update Date | 09/27/2012
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Provider Practice Location Address
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Address Line | 6715 GREENWOOD AVE N
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City | SEATTLE
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State | WA
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Zip | 98103-5225
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Country | US
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Telephone | 206-251-7109
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Fax |
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Provider Business Mailing Address
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Address Line | 6715 GREENWOOD AVE N
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City | SEATTLE
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State | WA
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Zip | 98103-5225
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Country | US
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Telephone | 206-251-7109
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Fax |
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Authorized Official
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Title or Position | EAST ASIAN MEDICINE PRACTITIONER
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Name | MYKOL RADZISZEWSKI
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Credential | MS, EAMP, LAC
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Telephone | 206-251-7109
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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 | AC60182088
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License Number State | WA
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