Provider Demographics
NPI:1063971703
Name:SOURCE NORTHWEST INTEGRATIVE MEDICINE
Entity type:Organization
Organization Name:SOURCE NORTHWEST INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:360-629-2222
Mailing Address - Street 1:7206 267TH ST NW STE 102
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-6269
Mailing Address - Country:US
Mailing Address - Phone:360-629-2222
Mailing Address - Fax:
Practice Address - Street 1:7206 267TH ST NW STE 102
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6269
Practice Address - Country:US
Practice Address - Phone:360-629-2222
Practice Address - Fax:360-629-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty