Provider Demographics
NPI:1942788484
Name:MASON MOORE WELLNESS LLC
Entity Type:Organization
Organization Name:MASON MOORE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMT
Authorized Official - Phone:503-748-9399
Mailing Address - Street 1:2100 SE BELMONT ST APT 410
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4572
Mailing Address - Country:US
Mailing Address - Phone:503-748-9399
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST STE 206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1089
Practice Address - Country:US
Practice Address - Phone:503-748-9399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC184969171100000X
ORLMT20000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty