Provider Demographics
NPI:1568819266
Name:IDEAL WELLNESS, PLLC
Entity type:Organization
Organization Name:IDEAL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:860-608-5019
Mailing Address - Street 1:16004 NORMANDY CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4321
Mailing Address - Country:US
Mailing Address - Phone:571-989-2001
Mailing Address - Fax:571-376-7015
Practice Address - Street 1:3310 NOBLE POND WAY STE 215
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1472
Practice Address - Country:US
Practice Address - Phone:571-989-2001
Practice Address - Fax:571-376-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207764261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy