Healthcare Provider Details

I. General information

NPI: 1730902941
Provider Name (Legal Business Name): WYNN STREET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10445 SW CANYON RD STE 114
BEAVERTON OR
97005-1913
US

IV. Provider business mailing address

10445 SW CANYON RD STE 114
BEAVERTON OR
97005-1913
US

V. Phone/Fax

Practice location:
  • Phone: 971-303-9360
  • Fax:
Mailing address:
  • Phone: 971-303-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: JODI WYNN TURNER
Title or Position: OWNER/MANAGER
Credential:
Phone: 971-303-9360