Provider Demographics
NPI:1225879836
Name:MYSTIQUE HEALTHCARE
Entity type:Organization
Organization Name:MYSTIQUE HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ARMANDO
Authorized Official - Last Name:LEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:206-422-9443
Mailing Address - Street 1:11541 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-8083
Mailing Address - Country:US
Mailing Address - Phone:206-422-9443
Mailing Address - Fax:
Practice Address - Street 1:11541 6TH AVE E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-8083
Practice Address - Country:US
Practice Address - Phone:206-422-9443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-06
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)