Provider Demographics
NPI:1831479724
Name:WHITE WILLOW ROAD HEALING CENTER, LLC
Entity type:Organization
Organization Name:WHITE WILLOW ROAD HEALING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EAST ASIAN MEDICINE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MYKOL
Authorized Official - Middle Name:
Authorized Official - Last Name:RADZISZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, EAMP, LAC
Authorized Official - Phone:206-251-7109
Mailing Address - Street 1:6715 GREENWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5225
Mailing Address - Country:US
Mailing Address - Phone:206-251-7109
Mailing Address - Fax:
Practice Address - Street 1:6715 GREENWOOD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5225
Practice Address - Country:US
Practice Address - Phone:206-251-7109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60182088171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty