=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194100255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAKURA RECOVERY AND WELLNESS, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2015
-----------------------------------------------------
Last Update Date | 07/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1675 SW MARLOW AVE STE 315
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-701-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1675 SW MARLOW AVE STE 315
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-701-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC NURSE PRACTITIONER/OWNE
-----------------------------------------------------
Name | JUSTIN RICE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 310-701-7242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 201403432NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------