Provider Demographics
NPI:1689934044
Name:FETTLE BOTANIC SUPPLY & COUNSEL
Entity Type:Organization
Organization Name:FETTLE BOTANIC SUPPLY & COUNSEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PURSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-234-7801
Mailing Address - Street 1:3327 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3327 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5046
Practice Address - Country:US
Practice Address - Phone:503-234-7801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-20
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1607251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management