Provider Demographics
NPI:1790181360
Name:NORTHSTAR WELLNESS LLC
Entity Type:Organization
Organization Name:NORTHSTAR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:WALLER
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:816-682-5819
Mailing Address - Street 1:810 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MO
Mailing Address - Zip Code:64085-1908
Mailing Address - Country:US
Mailing Address - Phone:816-682-5819
Mailing Address - Fax:855-682-5819
Practice Address - Street 1:810 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085-1908
Practice Address - Country:US
Practice Address - Phone:816-682-5819
Practice Address - Fax:855-682-5819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011011136261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service