Provider Demographics
NPI:1033605654
Name:NORTH WEST ROOTS WELLNESS CENTER
Entity Type:Organization
Organization Name:NORTH WEST ROOTS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:425-518-2337
Mailing Address - Street 1:827 MILLS PL NE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-9440
Mailing Address - Country:US
Mailing Address - Phone:425-518-2337
Mailing Address - Fax:425-888-1273
Practice Address - Street 1:17090 AVONDALE WAY NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4409
Practice Address - Country:US
Practice Address - Phone:425-518-2337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60455117225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty