Provider Demographics
NPI:1639510308
Name:LIVING WELL MED SPA
Entity Type:Organization
Organization Name:LIVING WELL MED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PFEFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:971-327-4355
Mailing Address - Street 1:1920 NW AMBERGLEN PKWY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6980
Mailing Address - Country:US
Mailing Address - Phone:971-327-4355
Mailing Address - Fax:
Practice Address - Street 1:1920 NW AMBERGLEN PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97006-6980
Practice Address - Country:US
Practice Address - Phone:971-327-4355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAD PFEFER MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21275261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty