MEDICARE: 5E COMMUNITY CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	WA-585	WA

General Provider Information

NPI Number	:	1457779738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5E COMMUNITY CLINIC, LLC

Provider Business Mailing Address
First Line	:	5424 BALLARD AVE NW
Second Line	:	SUITE 301
City	:	SEATTLE
State	:	WA
Zip	:	98107-4046
Country	:	US
Telephone Number	:	206-781-1371
Fax Number	:	206-781-1380

Provider Business Practice Location Address
First Line	:	5424 BALLARD AVE NW
Second Line	:	SUITE 301
City	:	SEATTLE
State	:	WA
Zip	:	98107-4046
Country	:	US
Telephone Number	:	206-781-1371
Fax Number	:	206-781-1380

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MARK R TIBEAU
Credential	:	EAMP, L.AC
Telephone Number	:	206-781-1371

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	04/03/2014

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