Provider Demographics
NPI:1164778221
Name:MAYA WHOLE HEALTH AT SOUTHPORT
Entity Type:Organization
Organization Name:MAYA WHOLE HEALTH AT SOUTHPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDIO COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-271-0200
Mailing Address - Street 1:1322 LAKE WASHINGTON BLVD N
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-0703
Mailing Address - Country:US
Mailing Address - Phone:425-271-0200
Mailing Address - Fax:206-309-3383
Practice Address - Street 1:1322 LAKE WASHINGTON BLVD N
Practice Address - Street 2:SUITE 3
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-0703
Practice Address - Country:US
Practice Address - Phone:425-271-0200
Practice Address - Fax:206-309-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty