Provider Demographics
NPI:1477138196
Name:WILDERNESS MEDICAL RELIEF LLC
Entity Type:Organization
Organization Name:WILDERNESS MEDICAL RELIEF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLENFELSZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:360-770-6924
Mailing Address - Street 1:802 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:AK
Practice Address - Zip Code:99921
Practice Address - Country:US
Practice Address - Phone:360-770-6924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service