Healthcare Provider Details

I. General information

NPI: 1265795991
Provider Name (Legal Business Name): EXPANSIVE BEING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 NE 19TH AVE
PORTLAND OR
97232-2829
US

IV. Provider business mailing address

314 NE 19TH AVE
PORTLAND OR
97232-2829
US

V. Phone/Fax

Practice location:
  • Phone: 503-239-8181
  • Fax: 503-548-4013
Mailing address:
  • Phone: 503-239-8181
  • Fax: 503-548-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1435
License Number StateOR

VIII. Authorized Official

Name: JESSICA MCMANUS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 541-521-9151