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General NPI Number Information
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NPI Number | 1326562547
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Entity Type | Organization
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Legal Business Name | WILDWOOD BODYWORK & MASSAGE ARTS
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Dates
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Enumeration Date | 07/29/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 2808 NE MARTIN LUTHER KING BLVD
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City | PORTLAND
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State | OR
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Zip | 97212-3060
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Country | US
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Telephone | 505-507-6161
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Fax |
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Provider Business Mailing Address
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Address Line | 3522 NE 46TH AVE
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City | PORTLAND
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State | OR
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Zip | 97213-1026
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Country | US
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Telephone | 505-507-6161
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARAH CHRISTINE DOBERNECK
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Credential | LMT
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Telephone | 505-507-6161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 22083
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License Number State | OR
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