Healthcare Provider Details

I. General information

NPI: 1043067580
Provider Name (Legal Business Name): GREAT RIVER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SW CASCADE AVE # 40F
STEVENSON WA
98648-6284
US

IV. Provider business mailing address

PO BOX 1351
STEVENSON WA
98648-1351
US

V. Phone/Fax

Practice location:
  • Phone: 509-416-6191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE KAMPMANN
Title or Position: OWNER
Credential: L.AC.
Phone: 509-416-6191