Provider Demographics
NPI:1902209513
Name:ENLOE WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ENLOE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:GERTRUDE
Authorized Official - Last Name:ENLOE
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, LAC,
Authorized Official - Phone:503-860-2372
Mailing Address - Street 1:15962 BOONES FERRY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4351
Mailing Address - Country:US
Mailing Address - Phone:503-860-2372
Mailing Address - Fax:
Practice Address - Street 1:15962 BOONES FERRY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4351
Practice Address - Country:US
Practice Address - Phone:503-860-2372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-27
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR162042171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1083059059OtherNPI TYPE 1