Provider Demographics
NPI:1407607633
Name:WILD MOSS WELLNESS LLC
Entity Type:Organization
Organization Name:WILD MOSS WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-676-3180
Mailing Address - Street 1:529 SE GRAND AVE STE 300D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:529 SE GRAND AVE STE 300D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2232
Practice Address - Country:US
Practice Address - Phone:503-410-3013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty