Provider Demographics
NPI:1346959038
Name:BUFFALO WELLNESS
Entity Type:Organization
Organization Name:BUFFALO WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KASANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-239-0401
Mailing Address - Street 1:3486 S SORENSON WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3114
Mailing Address - Country:US
Mailing Address - Phone:406-239-0401
Mailing Address - Fax:
Practice Address - Street 1:3486 S SORENSON WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-3114
Practice Address - Country:US
Practice Address - Phone:406-239-0401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health