Provider Demographics
NPI:1639714850
Name:PUYALLUP WELLNESS PLLC
Entity Type:Organization
Organization Name:PUYALLUP WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-473-3733
Mailing Address - Street 1:2802 S MERIDIAN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1402
Mailing Address - Country:US
Mailing Address - Phone:253-445-5032
Mailing Address - Fax:253-845-0129
Practice Address - Street 1:2802 S MERIDIAN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1402
Practice Address - Country:US
Practice Address - Phone:253-445-5032
Practice Address - Fax:253-845-0129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8945973Medicaid