Healthcare Provider Details

I. General information

NPI: 1235749987
Provider Name (Legal Business Name): ANKH WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5257 NE MARTIN LUTHER KING JR BLVD STE 202D
PORTLAND OR
97211-3283
US

IV. Provider business mailing address

8428 N BLISS ST
PORTLAND OR
97203-1177
US

V. Phone/Fax

Practice location:
  • Phone: 971-216-9732
  • Fax:
Mailing address:
  • Phone: 971-207-5652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEITH K CROWNER
Title or Position: EXECUTIVE DIRECTOR
Credential: CRM, PWS, CT
Phone: 971-216-9732