Healthcare Provider Details

I. General information

NPI: 1871715177
Provider Name (Legal Business Name): BELLEVUE WELLNESS GROUP, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10655 NE 4TH ST 101
BELLEVUE WA
98004-5035
US

IV. Provider business mailing address

10655 NE 4TH ST 101
BELLEVUE WA
98004-5035
US

V. Phone/Fax

Practice location:
  • Phone: 425-455-2225
  • Fax: 425-454-7767
Mailing address:
  • Phone: 425-455-2225
  • Fax: 425-454-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034656
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60201869
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60218348
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00044383
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTA60061061
License Number StateWA

VIII. Authorized Official

Name: DR. RAYMON KOONER
Title or Position: OWNER
Credential: DC
Phone: 425-455-2225