Provider Demographics
| NPI: | 1982771812 |
|---|---|
| Name: | NORTHWEST WELLNESS |
| Entity type: | Organization |
| Organization Name: | NORTHWEST WELLNESS |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | DAVID |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | OGLE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 888-837-8567 |
| Mailing Address - Street 1: | 5115 NE 76TH ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | VANCOUVER |
| Mailing Address - State: | WA |
| Mailing Address - Zip Code: | 98661-1357 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 888-837-8567 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 5115 NE 76TH ST |
| Practice Address - Street 2: | |
| Practice Address - City: | VANCOUVER |
| Practice Address - State: | WA |
| Practice Address - Zip Code: | 98661-1357 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 888-837-8567 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-11-29 |
| Last Update Date: | 2013-09-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 163WC1500X, 175F00000X, 174H00000X | ||
| OR | 50F0968535 | 291U00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
| No | 163WC1500X | Nursing Service Providers | Registered Nurse | Community Health | Group - Multi-Specialty |
| No | 175F00000X | Other Service Providers | Naturopath | Group - Multi-Specialty | |
| No | 174H00000X | Other Service Providers | Health Educator | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OR | R133000 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133001 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132974 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133022 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133049 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133004 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132942 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132992 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132979 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132980 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132996 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133002 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133011 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132934 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132972 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132987 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133021 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R132982 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133008 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
| OR | R133017 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
