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General NPI Number Information
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NPI Number | 1285458851
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Entity Type | Organization
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Legal Business Name | SD WELLNESS LLC
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Dates
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Enumeration Date | 11/11/2024
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Last Update Date | 01/16/2026
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Provider Practice Location Address
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Address Line | 3705 SE CESAR E CHAVEZ BLVD
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City | PORTLAND
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State | OR
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Zip | 97202-1704
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Country | US
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Telephone | 503-483-6394
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Fax | 503-483-6395
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Provider Business Mailing Address
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Address Line | 3705 SE CESAR E CHAVEZ BLVD
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City | PORTLAND
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State | OR
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Zip | 97202-1704
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Country | US
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Telephone | 503-483-6394
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Fax | 503-483-6395
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Authorized Official
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Title or Position | PHYSICIAN ASSOCIATE
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Name | SHONDELL DIAZ
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Credential | PA-C
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Telephone | 203-305-9859
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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 |
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License Number State |
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