Provider Demographics
NPI:1477083616
Name:LIVING WELLNESS NATUROPATHIC CLINIC LLC
Entity Type:Organization
Organization Name:LIVING WELLNESS NATUROPATHIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:ELLEN REVOIR
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-583-4245
Mailing Address - Street 1:3340 SE MORRISON ST APT 328
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3193
Mailing Address - Country:US
Mailing Address - Phone:503-583-4245
Mailing Address - Fax:503-419-6202
Practice Address - Street 1:7411 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2451
Practice Address - Country:US
Practice Address - Phone:503-227-1222
Practice Address - Fax:503-227-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2062261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center