Provider Demographics
NPI:1689965402
Name:ADVANCED WELLNESS CONNECTIONS, LLC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CONNECTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, GCFP, LMP
Authorized Official - Phone:425-282-0406
Mailing Address - Street 1:981 POWELL AVE SW STE 130
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2990
Mailing Address - Country:US
Mailing Address - Phone:425-282-0406
Mailing Address - Fax:425-282-0404
Practice Address - Street 1:981 POWELL AVE SW STE 130
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2990
Practice Address - Country:US
Practice Address - Phone:425-282-0406
Practice Address - Fax:425-282-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00008877261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1649358573OtherNPI INDIVIDUAL NUMBER