Provider Demographics
NPI:1669828315
Name:PORTLAND WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:PORTLAND WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-445-9133
Mailing Address - Street 1:105 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1228
Mailing Address - Country:US
Mailing Address - Phone:615-325-5000
Mailing Address - Fax:615-323-8400
Practice Address - Street 1:105 E MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1228
Practice Address - Country:US
Practice Address - Phone:615-325-5000
Practice Address - Fax:615-323-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000031162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty