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1255032926 NPI number — WILDER WELLNESS LLC

NPI Number: 1255032926
Health Care Provider/Practitioner: WILDER WELLNESS LLC

Information about “1255032926” NPI (WILDER WELLNESS LLC) exists in 1255032926 in HTML format HTML  |  1255032926 in plain Text format TXT  |  1255032926 in PDF (Portable Document Format) PDF  |  1255032926 in an XML format XML  formats.

NPI Number : 1255032926 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1255032926",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "WILDER WELLNESS LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "70 SW CENTURY DR",
    "SecondLineMailingAddress": "STE 100 PMB 1076",
    "MailingAddressCityName": "BEND",
    "MailingAddressStateName": "OR",
    "MailingAddressPostalCode": "97702",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "20225 JONATHON CT",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "BEND",
    "PracticeLocationAddressStateName": "OR",
    "PracticeLocationAddressPostalCode": "97703-8764",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "458-206-0904",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "03/10/2023",
    "LastUpdateDate": "03/10/2023",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "ALES",
    "AuthorizedOfficialFirstName": "KRISTEN",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "CEO, THERAPIST",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "MA, LPC",
    "AuthorizedOfficialTelephoneNumber": "831-345-2951",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "261QM0801X",
        "TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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