Provider Demographics
NPI:1689861064
Name:WILLMORE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WILLMORE WELLNESS CENTER LLC
Other - Org Name:WILLMORE WELLNESS CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:928-763-0807
Mailing Address - Street 1:3782 HIGHWAY 95
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8124
Mailing Address - Country:US
Mailing Address - Phone:928-763-0807
Mailing Address - Fax:928-763-0827
Practice Address - Street 1:3782 HIGHWAY 95
Practice Address - Street 2:SUITE 2
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8124
Practice Address - Country:US
Practice Address - Phone:928-763-0807
Practice Address - Fax:928-763-0827
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLMORE WELLNESS CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-28
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79128Medicare PIN