Provider Demographics
NPI:1497295521
Name:GREAT FOREST MEDICINE
Entity Type:Organization
Organization Name:GREAT FOREST MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EAST ASIAN MEDICINE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-305-8709
Mailing Address - Street 1:5609 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2015
Mailing Address - Country:US
Mailing Address - Phone:206-305-8709
Mailing Address - Fax:
Practice Address - Street 1:5609 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-2015
Practice Address - Country:US
Practice Address - Phone:206-305-8709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center