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General NPI Number Information
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NPI Number | 1023520814
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Entity Type | Organization
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Legal Business Name | CONCORDIA WELLNESS, LLC
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Dates
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Enumeration Date | 11/01/2017
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Last Update Date | 10/03/2020
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Provider Practice Location Address
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Address Line | 3014 NE KILLINGSWORTH ST
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City | PORTLAND
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State | OR
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Zip | 97211-6814
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Country | US
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Telephone | 503-449-7631
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Fax |
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Provider Business Mailing Address
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Address Line | 3014 NE KILLINGSWORTH ST
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City | PORTLAND
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State | OR
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Zip | 97211-6814
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Country | US
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Telephone | 503-449-7631
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | KIM MAGRAW
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Credential | LMT
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Telephone | 503-449-7631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4194
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 19492
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License Number State | OR
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