Provider Demographics
NPI:1699001487
Name:CARRUTH, MICHAEL EDWARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:CARRUTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1821
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-5014
Mailing Address - Country:US
Mailing Address - Phone:360-462-8087
Mailing Address - Fax:360-462-8088
Practice Address - Street 1:1635 OLYMPIC HWY N
Practice Address - Street 2:SUITE 102A
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3065
Practice Address - Country:US
Practice Address - Phone:360-462-8087
Practice Address - Fax:360-462-8088
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60114584171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist