Provider Demographics
NPI:1306003645
Name:RINNOVARE LASER AND WELLNESS
Entity Type:Organization
Organization Name:RINNOVARE LASER AND WELLNESS
Other - Org Name:RINNOVARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:CA
Authorized Official - Phone:503-667-9300
Mailing Address - Street 1:23479 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2962
Mailing Address - Country:US
Mailing Address - Phone:503-667-9300
Mailing Address - Fax:503-667-4975
Practice Address - Street 1:23479 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2962
Practice Address - Country:US
Practice Address - Phone:503-667-9300
Practice Address - Fax:503-667-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3026111N00000X
OR0932175F00000X
OR23982261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU72454Medicare UPIN