Provider Demographics
NPI:1114387560
Name:HEAVENLY ANCESTOR 5 ELEMENT ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:HEAVENLY ANCESTOR 5 ELEMENT ACUPUNCTURE LLC
Other - Org Name:5 ELEMENT ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THOMASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:EAMP, LAC, DIPLAC
Authorized Official - Phone:206-245-6119
Mailing Address - Street 1:7701 WESTERLY LN NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2698
Mailing Address - Country:US
Mailing Address - Phone:206-245-6119
Mailing Address - Fax:
Practice Address - Street 1:7701 WESTERLY LN NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2698
Practice Address - Country:US
Practice Address - Phone:206-245-6119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-27
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60354712171100000X
MI5401000102171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty