Provider Demographics
NPI:1467731380
Name:WOODSTOCK WELLNESS CENTER
Entity Type:Organization
Organization Name:WOODSTOCK WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:TISCI
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-777-2776
Mailing Address - Street 1:4512 SE WOODSTOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6274
Mailing Address - Country:US
Mailing Address - Phone:503-777-2776
Mailing Address - Fax:
Practice Address - Street 1:4512 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6274
Practice Address - Country:US
Practice Address - Phone:503-777-2776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty