Healthcare Provider Details

I. General information

NPI: 1285159251
Provider Name (Legal Business Name): WILD EARTH WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

IV. Provider business mailing address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

V. Phone/Fax

Practice location:
  • Phone: 503-310-2622
  • Fax:
Mailing address:
  • Phone: 503-310-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number7615
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1164547634
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: MRS. JENNIFER MARIE BOOM
Title or Position: OWNER
Credential: LMT
Phone: 503-310-2622