Provider Demographics
NPI:1093413452
Name:WHOLISTIC WELLNESS OF THE WEST LLC
Entity Type:Organization
Organization Name:WHOLISTIC WELLNESS OF THE WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-255-3905
Mailing Address - Street 1:1755 COBURG RD UNIT 401
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4984
Mailing Address - Country:US
Mailing Address - Phone:541-255-3905
Mailing Address - Fax:541-255-3959
Practice Address - Street 1:1755 COBURG RD UNIT 401
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4984
Practice Address - Country:US
Practice Address - Phone:541-255-3905
Practice Address - Fax:541-255-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR137345Medicaid