Provider Demographics
NPI:1821431545
Name:KELLY PRILL NATUROPATHIC PHYSCIAN, LLC
Entity Type:Organization
Organization Name:KELLY PRILL NATUROPATHIC PHYSCIAN, LLC
Other - Org Name:ELEMENTAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRILL
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:971-270-0220
Mailing Address - Street 1:6715 N WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5252
Mailing Address - Country:US
Mailing Address - Phone:971-270-0220
Mailing Address - Fax:
Practice Address - Street 1:200 NE 20TH AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3094
Practice Address - Country:US
Practice Address - Phone:971-270-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1853175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty