Provider Demographics
NPI:1114460748
Name:WATERSHED COMMUNITY WELLNESS LLC
Entity Type:Organization
Organization Name:WATERSHED COMMUNITY WELLNESS LLC
Other - Org Name:WATERSHED WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-806-5174
Mailing Address - Street 1:1490 COMMERCIAL ST
Mailing Address - Street 2:202
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3800
Mailing Address - Country:US
Mailing Address - Phone:503-974-0914
Mailing Address - Fax:888-972-3725
Practice Address - Street 1:1490 COMMERCIAL ST
Practice Address - Street 2:202
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3800
Practice Address - Country:US
Practice Address - Phone:503-974-0914
Practice Address - Fax:888-972-3725
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATERSHED COMMUNITY WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150225171100000X
OR12190172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty