Provider Demographics
NPI:1760945968
Name:LIVING WELL KENT COLLABORATIVE
Entity Type:Organization
Organization Name:LIVING WELL KENT COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAMSO
Authorized Official - Middle Name:
Authorized Official - Last Name:ISSAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-457-2964
Mailing Address - Street 1:10605 SE 240TH ST # 232
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4903
Mailing Address - Country:US
Mailing Address - Phone:253-457-2964
Mailing Address - Fax:
Practice Address - Street 1:515 W HARRISON ST STE 208
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4403
Practice Address - Country:US
Practice Address - Phone:253-457-2964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty