Provider Demographics
NPI:1114431079
Name:MIRACLE ISLAND PLLC
Entity Type:Organization
Organization Name:MIRACLE ISLAND PLLC
Other - Org Name:TAIJI ACUPUNCTURE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HAIMING
Authorized Official - Middle Name:
Authorized Official - Last Name:SHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-519-9039
Mailing Address - Street 1:7605 SE 27TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2852
Mailing Address - Country:US
Mailing Address - Phone:206-519-9039
Mailing Address - Fax:
Practice Address - Street 1:7605 SE 27TH ST STE 103
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2852
Practice Address - Country:US
Practice Address - Phone:206-519-9039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60696857171100000X
WAMA60654589225700000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty