Provider Demographics
NPI:1437715216
Name:PACIFIC NORTHWEST WELLNESS LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-266-0421
Mailing Address - Street 1:106 E 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4033
Mailing Address - Country:US
Mailing Address - Phone:971-266-0421
Mailing Address - Fax:
Practice Address - Street 1:106 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4033
Practice Address - Country:US
Practice Address - Phone:971-266-0421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1346542503Medicaid