Provider Demographics
NPI:1457790826
Name:GROUNDSWELL INTEGRATIVE HEALTHCARE INC.
Entity Type:Organization
Organization Name:GROUNDSWELL INTEGRATIVE HEALTHCARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWSON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-399-1400
Mailing Address - Street 1:374 OWENS ST SE
Mailing Address - Street 2:#100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-399-1400
Mailing Address - Fax:503-399-1406
Practice Address - Street 1:374 OWENS ST SE
Practice Address - Street 2:#100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4183
Practice Address - Country:US
Practice Address - Phone:503-399-1400
Practice Address - Fax:503-399-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1073659009Medicare PIN