Healthcare Provider Details

I. General information

NPI: 1598256281
Provider Name (Legal Business Name): OREGON WELLNESS NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 CHERRY AVE NE
KEIZER OR
97303
US

IV. Provider business mailing address

3410 CHERRY AVE NE
KEIZER OR
97303-4924
US

V. Phone/Fax

Practice location:
  • Phone: 503-304-3655
  • Fax:
Mailing address:
  • Phone: 503-304-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAVINIA GOTO
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 503-304-3408