Provider Demographics
NPI:1942849872
Name:CARLTON WELLNESS STUDIO LLC
Entity Type:Organization
Organization Name:CARLTON WELLNESS STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-852-3099
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-0601
Mailing Address - Country:US
Mailing Address - Phone:503-852-3099
Mailing Address - Fax:503-852-3155
Practice Address - Street 1:455 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:OR
Practice Address - Zip Code:97111-8904
Practice Address - Country:US
Practice Address - Phone:503-852-3099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty