Healthcare Provider Details

I. General information

NPI: 1588131411
Provider Name (Legal Business Name): MIND & BODY WELLNESS OF BEAVERTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 SW ANGEL AVE APT 108
BEAVERTON OR
97005-2717
US

IV. Provider business mailing address

4545 SW ANGEL AVE APT 108
BEAVERTON OR
97005-2717
US

V. Phone/Fax

Practice location:
  • Phone: 503-891-1389
  • Fax:
Mailing address:
  • Phone: 503-891-1389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER KENT STEWART
Title or Position: CHIROPRACTIC PHYSICIAN
Credential: DC
Phone: 503-891-1389