Provider Demographics
NPI:1245497791
Name:EQUILIBRIA LLC
Entity type:Organization
Organization Name:EQUILIBRIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BODE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-221-2155
Mailing Address - Street 1:1536 NW 23RD AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2618
Mailing Address - Country:US
Mailing Address - Phone:503-221-2155
Mailing Address - Fax:503-274-4159
Practice Address - Street 1:1536 NW 23RD AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2618
Practice Address - Country:US
Practice Address - Phone:503-221-2155
Practice Address - Fax:503-274-4159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR661684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty