Provider Demographics
NPI:1184895518
Name:THE WELLNESS CLINIC
Entity type:Organization
Organization Name:THE WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-957-5750
Mailing Address - Street 1:2395 NW STEWART PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-957-5750
Mailing Address - Fax:541-957-5766
Practice Address - Street 1:2395 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-5653
Practice Address - Country:US
Practice Address - Phone:541-957-5750
Practice Address - Fax:541-957-5766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287168Medicaid
OR287168Medicaid