Healthcare Provider Details

I. General information

NPI: 1437715216
Provider Name (Legal Business Name): PACIFIC NORTHWEST WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E 16TH AVE
EUGENE OR
97401-4033
US

IV. Provider business mailing address

106 E 16TH AVE
EUGENE OR
97401-4033
US

V. Phone/Fax

Practice location:
  • Phone: 971-266-0421
  • Fax:
Mailing address:
  • Phone: 971-266-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PRISCILLA MYCO
Title or Position: OWNER
Credential:
Phone: 719-266-0421