Healthcare Provider Details

I. General information

NPI: 1265704209
Provider Name (Legal Business Name): AMBER WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1944 NE 45TH AVE.
PORTLAND OR
97213
US

IV. Provider business mailing address

1944 NE 45TH AVE.
PORTLAND OR
97213
US

V. Phone/Fax

Practice location:
  • Phone: 971-319-0045
  • Fax: 503-296-5712
Mailing address:
  • Phone: 971-319-0045
  • Fax: 503-296-5712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1291
License Number StateOR

VIII. Authorized Official

Name: DR. LISA ANNE DICKINSON
Title or Position: OWNER/NATUROPATHIC PHYSICIAN
Credential: ND
Phone: 971-319-0045