Provider Demographics
NPI:1629110945
Name:FAMILY WELLNESS CENTER PC
Entity Type:Organization
Organization Name:FAMILY WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-260-2773
Mailing Address - Street 1:1000 SE TECH CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5547
Mailing Address - Country:US
Mailing Address - Phone:360-260-2773
Mailing Address - Fax:360-260-2217
Practice Address - Street 1:1000 SE TECH CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5547
Practice Address - Country:US
Practice Address - Phone:360-260-2773
Practice Address - Fax:360-260-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115118300Medicare ID - Type Unspecified