Provider Demographics
NPI:1326453515
Name:PORTLAND HEALING SPACE LLC
Entity Type:Organization
Organization Name:PORTLAND HEALING SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-894-9437
Mailing Address - Street 1:1830 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3912
Mailing Address - Country:US
Mailing Address - Phone:503-894-9437
Mailing Address - Fax:503-894-9437
Practice Address - Street 1:1830 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3912
Practice Address - Country:US
Practice Address - Phone:503-894-9437
Practice Address - Fax:503-894-9437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5084111N00000X
171100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty