Healthcare Provider Details

I. General information

NPI: 1770167348
Provider Name (Legal Business Name): IRIDESCENT WELLNESS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 03/07/2023
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 GARDEN AVE STE 203
EUGENE OR
97403-1965
US

IV. Provider business mailing address

2312 W 28TH AVE
EUGENE OR
97405-1426
US

V. Phone/Fax

Practice location:
  • Phone: 503-739-5705
  • Fax:
Mailing address:
  • Phone: 503-739-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. RANDA JILL KUCEY
Title or Position: FNP/OWNER
Credential: DNP
Phone: 503-739-5705