Healthcare Provider Details

I. General information

NPI: 1063671121
Provider Name (Legal Business Name): WILDWOOD MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 INDIA ST
PORTLAND ME
04101-4210
US

IV. Provider business mailing address

PO BOX 7412
PORTLAND ME
04112
US

V. Phone/Fax

Practice location:
  • Phone: 207-347-7132
  • Fax: 207-839-2197
Mailing address:
  • Phone: 207-347-7132
  • Fax: 207-839-2197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC281
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC308
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3116
License Number StateME

VIII. Authorized Official

Name: MR. DANIEL KATZ
Title or Position: PRESIDENT
Credential: PT NC
Phone: 207-347-7132