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General NPI Number Information
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NPI Number | 1316236847
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Entity Type | Organization
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Legal Business Name | WHOLE LIFE VITALITY
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Dates
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Enumeration Date | 04/05/2011
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 3942 SE HAWTHORNE BLVD
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City | PORTLAND
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State | OR
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Zip | 97214-5242
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Country | US
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Telephone | 503-208-4546
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Fax | 503-715-5789
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Provider Business Mailing Address
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Address Line | 4110 SE HAWTHORNE BLVD # 178
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City | PORTLAND
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State | OR
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Zip | 97214-5246
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Country | US
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Telephone | 503-482-9092
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Fax | 503-715-5789
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Authorized Official
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Title or Position | OWNER
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Name | GIBRAN KEKOA RAMOS
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Credential |
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Telephone | 503-482-9092
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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 | 63999099
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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