Provider Demographics
NPI:1104157858
Name:RISING TIDE NATURAL MEDICINE
Entity type:Organization
Organization Name:RISING TIDE NATURAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLINTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:207-865-1222
Mailing Address - Street 1:4985 TWIN LAKES RD
Mailing Address - Street 2:APT 87
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3894
Mailing Address - Country:US
Mailing Address - Phone:303-501-0819
Mailing Address - Fax:
Practice Address - Street 1:2321 30TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1103
Practice Address - Country:US
Practice Address - Phone:303-501-0819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MENP227175F00000X
175L00000X
CO1127171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Multi-Specialty