Provider Demographics
NPI:1073736435
Name:A BODY OF WISDOM NATURAL FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:A BODY OF WISDOM NATURAL FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-665-9111
Mailing Address - Street 1:119 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7403
Mailing Address - Country:US
Mailing Address - Phone:503-665-9111
Mailing Address - Fax:503-665-0110
Practice Address - Street 1:119 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7403
Practice Address - Country:US
Practice Address - Phone:503-665-9111
Practice Address - Fax:503-665-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1079175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty