Provider Demographics
NPI:1124679519
Name:WISHING WELL CLINIC & SPA, LLC
Entity type:Organization
Organization Name:WISHING WELL CLINIC & SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERRALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:419-394-1402
Mailing Address - Street 1:4 E. AUGLAIZE
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895
Mailing Address - Country:US
Mailing Address - Phone:419-394-1402
Mailing Address - Fax:419-394-3597
Practice Address - Street 1:153 E, SPRING STREET
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885
Practice Address - Country:US
Practice Address - Phone:419-394-1402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty