Provider Demographics
NPI:1801230776
Name:SALEM WELLNESS CLINIC
Entity Type:Organization
Organization Name:SALEM WELLNESS CLINIC
Other - Org Name:SALEM WOMEN'S CLINIC, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDESOUKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-399-2444
Mailing Address - Street 1:1395 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4276
Mailing Address - Country:US
Mailing Address - Phone:503-399-2444
Mailing Address - Fax:503-581-3960
Practice Address - Street 1:1395 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4276
Practice Address - Country:US
Practice Address - Phone:503-399-2444
Practice Address - Fax:503-581-3960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALEM WOMEN'S CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-23
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286300Medicaid
OR286300Medicaid