Provider Demographics
NPI:1215218706
Name:PACIFIC WAY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PACIFIC WAY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODOSIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-738-9796
Mailing Address - Street 1:1289 PACIFIC WAY
Mailing Address - Street 2:
Mailing Address - City:GEARHART
Mailing Address - State:OR
Mailing Address - Zip Code:97138-4360
Mailing Address - Country:US
Mailing Address - Phone:503-738-9796
Mailing Address - Fax:503-717-1378
Practice Address - Street 1:1289 PACIFIC WAY
Practice Address - Street 2:
Practice Address - City:GEARHART
Practice Address - State:OR
Practice Address - Zip Code:97138-4360
Practice Address - Country:US
Practice Address - Phone:503-738-9796
Practice Address - Fax:503-717-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty