Provider Demographics
NPI:1972761187
Name:WALDO WELLNESS GROUP PC
Entity type:Organization
Organization Name:WALDO WELLNESS GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KELLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-333-2533
Mailing Address - Street 1:7210 WORNALL RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1345
Mailing Address - Country:US
Mailing Address - Phone:816-333-2533
Mailing Address - Fax:816-333-2586
Practice Address - Street 1:7210 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-1345
Practice Address - Country:US
Practice Address - Phone:816-333-2533
Practice Address - Fax:816-333-2586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-26
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007030924111N00000X
MO33655207Q00000X
MO20110310891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty