Provider Demographics
NPI:1730816661
Name:WILDWOOD WELLNESS LLC
Entity type:Organization
Organization Name:WILDWOOD WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-249-5170
Mailing Address - Street 1:312 WARNER AVE S
Mailing Address - Street 2:
Mailing Address - City:WILLERNIE
Mailing Address - State:MN
Mailing Address - Zip Code:55090-7702
Mailing Address - Country:US
Mailing Address - Phone:651-249-5170
Mailing Address - Fax:
Practice Address - Street 1:744 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1852
Practice Address - Country:US
Practice Address - Phone:651-300-4377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1538758479Medicaid