Healthcare Provider Details

I. General information

NPI: 1508242900
Provider Name (Legal Business Name): PUYALLUP WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 39TH AVE SW STE F
PUYALLUP WA
98373-3692
US

IV. Provider business mailing address

803 39TH AVE SW STE F
PUYALLUP WA
98373-3692
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-1055
  • Fax: 253-848-5533
Mailing address:
  • Phone: 253-848-1055
  • Fax: 253-848-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT00001550
License Number StateWA

VIII. Authorized Official

Name: ROMAN KRUPA
Title or Position: OWNER/ MEDICAL DIRECTOR
Credential: ND
Phone: 253-848-1055