Provider Demographics
NPI:1255351714
Name:FASA FAMILY WELLNESS, PLLC
Entity type:Organization
Organization Name:FASA FAMILY WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-754-3338
Mailing Address - Street 1:PO BOX 825159
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-5159
Mailing Address - Country:US
Mailing Address - Phone:360-338-0004
Mailing Address - Fax:360-515-0744
Practice Address - Street 1:1610 BISHOP RD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7303
Practice Address - Country:US
Practice Address - Phone:360-754-3338
Practice Address - Fax:360-753-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602208923261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047753Medicaid
WA7122203Medicaid
WA50D2089344OtherCLIA WAIVER
WA7122203Medicaid
WA2047753Medicaid