Provider Demographics
NPI:1639989205
Name:WILDWOOD ELECTROLYSIS LLC
Entity type:Organization
Organization Name:WILDWOOD ELECTROLYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ELECTROLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAY
Authorized Official - Middle Name:FOREST
Authorized Official - Last Name:WITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:LE
Authorized Official - Phone:541-805-9282
Mailing Address - Street 1:8803 N TYNDALL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7029
Mailing Address - Country:US
Mailing Address - Phone:541-805-9282
Mailing Address - Fax:
Practice Address - Street 1:833 SE MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3410
Practice Address - Country:US
Practice Address - Phone:503-251-5902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty