Healthcare Provider Details

I. General information

NPI: 1164206256
Provider Name (Legal Business Name): PRAIRIE WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13510 NE 228TH CT
BRUSH PRAIRIE WA
98606-4201
US

IV. Provider business mailing address

13510 NE 228TH CT
BRUSH PRAIRIE WA
98606-4201
US

V. Phone/Fax

Practice location:
  • Phone: 360-771-4018
  • Fax:
Mailing address:
  • Phone: 360-771-4018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MEGAN ROSIN
Title or Position: OWNER
Credential:
Phone: 360-771-4018