Provider Demographics
NPI:1104066836
Name:EMERALD VINE PLLC
Entity type:Organization
Organization Name:EMERALD VINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAINA
Authorized Official - Middle Name:MARIKO
Authorized Official - Last Name:AKIDAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-347-0777
Mailing Address - Street 1:142 NW CANAL ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4933
Mailing Address - Country:US
Mailing Address - Phone:206-347-0777
Mailing Address - Fax:888-254-3281
Practice Address - Street 1:142 NW CANAL ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4933
Practice Address - Country:US
Practice Address - Phone:206-347-0777
Practice Address - Fax:888-254-3281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025243172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty