Provider Demographics
NPI:1932436896
Name:WATERSHED COMMUNITY WELLNESS LLC
Entity Type:Organization
Organization Name:WATERSHED COMMUNITY WELLNESS LLC
Other - Org Name:WATERSHED COMMUNITY WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-820-8040
Mailing Address - Street 1:1988 SE LADD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4737
Mailing Address - Country:US
Mailing Address - Phone:503-820-8040
Mailing Address - Fax:503-564-0180
Practice Address - Street 1:1988 SE LADD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4737
Practice Address - Country:US
Practice Address - Phone:503-820-8040
Practice Address - Fax:503-564-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150225171100000X
OR12190172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty