Provider Demographics
NPI:1699330373
Name:VERT. FITNESS & WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:VERT. FITNESS & WELLNESS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-999-9848
Mailing Address - Street 1:4444 LACEY BLVD SE STE E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5730
Mailing Address - Country:US
Mailing Address - Phone:360-999-9848
Mailing Address - Fax:
Practice Address - Street 1:4444 LACEY BLVD SE STE E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5730
Practice Address - Country:US
Practice Address - Phone:360-999-9848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2134869Medicaid