Provider Demographics
NPI:1700946498
Name:TIBEAU, MARK RICHARD (LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:TIBEAU
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5424 BALLARD AVE NW STE 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4046
Mailing Address - Country:US
Mailing Address - Phone:206-781-1371
Mailing Address - Fax:206-781-1380
Practice Address - Street 1:5424 BALLARD AVE NW STE 301
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4046
Practice Address - Country:US
Practice Address - Phone:206-781-1371
Practice Address - Fax:206-781-1380
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC-585171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist