=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326999699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN OREGON HOLISTIC WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2026
-----------------------------------------------------
Last Update Date | 02/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 SW 4TH ST
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-761-1487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3685 WINDY CREEK RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97442-9786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-777-0250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | PHILIP ABRAHAM LEVENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-777-0250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------