Provider Demographics
NPI:1861495640
Name:FASA FAMILY WELLNESS, PLLC
Entity Type:Organization
Organization Name:FASA FAMILY WELLNESS, PLLC
Other - Org Name:ANKLE & FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KREIGHBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-909-1920
Mailing Address - Street 1:1114 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3842
Mailing Address - Country:US
Mailing Address - Phone:360-577-3682
Mailing Address - Fax:360-577-1871
Practice Address - Street 1:1114 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3842
Practice Address - Country:US
Practice Address - Phone:360-577-3682
Practice Address - Fax:360-577-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000488213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5124580001Medicare NSC