1255351714 NPI number — FASA FAMILY WELLNESS, PLLC

Table of content: (NPI 1255351714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255351714 NPI number — FASA FAMILY WELLNESS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FASA FAMILY WELLNESS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255351714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1610 BISHOP RD SW STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUMWATER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98512-7303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-338-0004
Provider Business Mailing Address Fax Number:
360-515-0744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 BISHOP RD SW
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TUMWATER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98512-7303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-754-3338
Provider Business Practice Location Address Fax Number:
360-753-4861
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EBERHARD
Authorized Official First Name:
DANA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
360-706-2767

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  602208923 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7122203 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2047753 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50D2089344 . This is a "CLIA WAIVER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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