Provider Demographics
NPI:1043695547
Name:MAGNOLIA NATUROPATHIC MEDICINE, LLC
Entity Type:Organization
Organization Name:MAGNOLIA NATUROPATHIC MEDICINE, LLC
Other - Org Name:MAGNOLIA NATUROPATHIC MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NATUROPATHIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ELAYNE
Authorized Official - Last Name:FIRETAG
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:843-209-3966
Mailing Address - Street 1:803 39TH AVE SW STE F
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3692
Mailing Address - Country:US
Mailing Address - Phone:253-848-1055
Mailing Address - Fax:253-848-5533
Practice Address - Street 1:803 39TH AVE SW STE F
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3692
Practice Address - Country:US
Practice Address - Phone:253-848-1055
Practice Address - Fax:253-848-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-25
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60524427261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1235537234OtherPROVIDER NPI