=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003723289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMAL CARE WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2026
-----------------------------------------------------
Last Update Date | 08/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97900 SHOPPING CENTER AVE STE 14
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-9412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 458-260-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97900 SHOPPING CENTER AVE STE 14
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-9412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 458-260-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALISHA MARIE QUAST
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 458-260-3090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------