Provider Demographics
NPI:1780716738
Name:CORE VITALITY CLINIC
Entity type:Organization
Organization Name:CORE VITALITY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:541-602-0260
Mailing Address - Street 1:442 NW 4TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6491
Mailing Address - Country:US
Mailing Address - Phone:541-602-0260
Mailing Address - Fax:541-753-4217
Practice Address - Street 1:442 NW 4TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6491
Practice Address - Country:US
Practice Address - Phone:541-602-0260
Practice Address - Fax:541-753-4217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2034175F00000X
OR2033175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty