Provider Demographics
NPI:1801143169
Name:HEALTHY LIVING LIBERTY LAKE
Entity type:Organization
Organization Name:HEALTHY LIVING LIBERTY LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-924-6199
Mailing Address - Street 1:2207 N MOLTER RD
Mailing Address - Street 2:STE 203
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7570
Mailing Address - Country:US
Mailing Address - Phone:509-924-6199
Mailing Address - Fax:509-891-9806
Practice Address - Street 1:2207 N MOLTER RD
Practice Address - Street 2:STE 203
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7570
Practice Address - Country:US
Practice Address - Phone:509-924-6199
Practice Address - Fax:509-891-9806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028821261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center