Basic Information
| Provider Information | |||||||||
| NPI: | 1194812305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST HEALTHCARE AND WELLNESS CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 JADWIN AVE | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1516 JADWIN AVE | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | LLOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5099467646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00019527 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1952358954 | 01 | NPI | OTHER | PENDING | 05 | WA | MEDICAID |