Healthcare Provider Details

I. General information

NPI: 1114460748
Provider Name (Legal Business Name): WATERSHED COMMUNITY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 COMMERCIAL ST 202
ASTORIA OR
97103-3800
US

IV. Provider business mailing address

1490 COMMERCIAL ST 202
ASTORIA OR
97103-3800
US

V. Phone/Fax

Practice location:
  • Phone: 503-974-0914
  • Fax: 888-972-3725
Mailing address:
  • Phone: 503-974-0914
  • Fax: 888-972-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC150225
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number12190
License Number StateOR

VIII. Authorized Official

Name: ERIC GREY
Title or Position: OWNER / MEMBER
Credential:
Phone: 503-806-5174