Provider Demographics
NPI:1407345804
Name:GAIA MED PLLC
Entity Type:Organization
Organization Name:GAIA MED PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZURA
Authorized Official - Suffix:
Authorized Official - Credentials:ND, RD, EAMP
Authorized Official - Phone:206-508-1300
Mailing Address - Street 1:5122 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4121
Mailing Address - Country:US
Mailing Address - Phone:206-900-9798
Mailing Address - Fax:
Practice Address - Street 1:5122 25TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-900-9798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL918610133V00000X
WA60245607171100000X
WA60245488175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2MP000004632060Medicaid