Provider Demographics
NPI:1326316928
Name:HEALING PONDS NORTHWEST LLC
Entity Type:Organization
Organization Name:HEALING PONDS NORTHWEST LLC
Other - Org Name:SPORTS MEDICINE NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:XENIA
Authorized Official - Last Name:POND
Authorized Official - Suffix:
Authorized Official - Credentials:EAMP
Authorized Official - Phone:206-795-6462
Mailing Address - Street 1:2324 CALIFORNIA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2403
Mailing Address - Country:US
Mailing Address - Phone:206-682-0676
Mailing Address - Fax:
Practice Address - Street 1:2324 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2403
Practice Address - Country:US
Practice Address - Phone:206-682-0676
Practice Address - Fax:206-623-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60076566111N00000X
AC60091482171100000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty