| Tidal Balanced Wellness Center | |
|
325 Tacoma Ave S Ste 1 Tacoma WA 98402-2550 | |
| (757) 921-7704 | |
| Not Available |
| Full Name | Tidal Balanced Wellness Center |
|---|---|
| Speciality | Clinic/Center |
| Location | 325 Tacoma Ave S Ste 1, Tacoma, Washington |
| Authorized Official Name and Position | Shannon Barello Crayton (OWNER) |
| Authorized Official Contact | 7579217704 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Tidal Balanced Wellness Center 325 Tacoma Ave S Ste 1 Tacoma WA 98402-2550 Ph: (757) 921-7704 | Tidal Balanced Wellness Center 325 Tacoma Ave S Ste 1 Tacoma WA 98402-2550 Ph: (757) 921-7704 |
| NPI Number | 1558958991 |
|---|---|
| Provider Enumeration Date | 12/30/2020 |
| Last Update Date | 04/10/2024 |
| Medicare PECOS PAC ID | 1557778842 |
|---|---|
| Medicare Enrollment ID | O20210405000380 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1558958991 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Shannon B Crayton |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1235372004 PECOS PAC ID: 8628120193 Enrollment ID: I20180509001406 |
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