Provider Demographics
NPI:1639556293
Name:AUTHENTIC HEALING WELLNESS PDX CENTER
Entity Type:Organization
Organization Name:AUTHENTIC HEALING WELLNESS PDX CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAWLA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-998-2678
Mailing Address - Street 1:333 S FLOWER ST STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3797
Mailing Address - Country:US
Mailing Address - Phone:503-998-2678
Mailing Address - Fax:
Practice Address - Street 1:333 S FLOWER ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3797
Practice Address - Country:US
Practice Address - Phone:503-998-2678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00489171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1376768093OtherNPI