Provider Demographics
NPI:1760755425
Name:SACRED ROOT ACUPUNCTURE & NATUROPATHIC MEDICINE
Entity Type:Organization
Organization Name:SACRED ROOT ACUPUNCTURE & NATUROPATHIC MEDICINE
Other - Org Name:SACRED ROOT MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER, PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC,
Authorized Official - Phone:425-256-7798
Mailing Address - Street 1:611 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3096
Mailing Address - Country:US
Mailing Address - Phone:425-256-7798
Mailing Address - Fax:425-274-3409
Practice Address - Street 1:611 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3096
Practice Address - Country:US
Practice Address - Phone:425-229-1070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60244418171100000X
WA60515973175F00000X
ORAC155797261Q00000X
WA#AC60244418261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty