Provider Demographics
NPI:1043694433
Name:ELEMENT WELLNESS AND SPORTS REHABILITATION
Entity Type:Organization
Organization Name:ELEMENT WELLNESS AND SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ENOCH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-445-7999
Mailing Address - Street 1:5331 SW MACADAM AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3848
Mailing Address - Country:US
Mailing Address - Phone:503-445-7999
Mailing Address - Fax:503-445-7997
Practice Address - Street 1:5331 SW MACADAM AVE STE 105
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3848
Practice Address - Country:US
Practice Address - Phone:503-445-7999
Practice Address - Fax:503-445-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21383225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty