Provider Demographics
NPI:1871715177
Name:BELLEVUE WELLNESS GROUP, PS
Entity type:Organization
Organization Name:BELLEVUE WELLNESS GROUP, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-455-2225
Mailing Address - Street 1:10655 NE 4TH ST
Mailing Address - Street 2:101
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5035
Mailing Address - Country:US
Mailing Address - Phone:425-455-2225
Mailing Address - Fax:425-454-7767
Practice Address - Street 1:10655 NE 4TH ST
Practice Address - Street 2:101
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5035
Practice Address - Country:US
Practice Address - Phone:425-455-2225
Practice Address - Fax:425-454-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034656111N00000X
WAAC60201869171100000X
WANT60218348175F00000X
WAMD00044383207R00000X
225700000X
WATA60061061363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6498900001Medicare NSC