Provider Demographics
NPI:1275921660
Name:ADVANCED WELLNESS CENTER
Entity Type:Organization
Organization Name:ADVANCED WELLNESS CENTER
Other - Org Name:THE ADVANCED WELLNESS CENTER PDX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-389-5545
Mailing Address - Street 1:3150 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4029
Mailing Address - Country:US
Mailing Address - Phone:503-389-5545
Mailing Address - Fax:888-847-1238
Practice Address - Street 1:3150 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4029
Practice Address - Country:US
Practice Address - Phone:503-389-5545
Practice Address - Fax:888-847-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
ORAC171030305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization