Healthcare Provider Details

I. General information

NPI: 1457056988
Provider Name (Legal Business Name): CONSCIOUS HEALING COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13019 SE LINCOLN ST
PORTLAND OR
97233-1435
US

IV. Provider business mailing address

13019 SE LINCOLN ST
PORTLAND OR
97233-1435
US

V. Phone/Fax

Practice location:
  • Phone: 646-740-1538
  • Fax:
Mailing address:
  • Phone: 646-740-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. GRETCHEN L GATZKE
Title or Position: OWNER
Credential: DC
Phone: 646-740-1538