=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861942914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILY ACUPUNCTURE HEALING SPACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1912 GRAND BLVD
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-718-7897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1912 GRAND BLVD
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-718-7897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTORE OF ACUPUNCTURE AND OM
-----------------------------------------------------
Name | MIN-HWA LEE
-----------------------------------------------------
Credential | DAOM
-----------------------------------------------------
Telephone | 360-718-7897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC 60651194
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------