=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477083616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING WELLNESS NATUROPATHIC CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 06/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7411 SE POWELL BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-227-1222
-----------------------------------------------------
Fax | 503-227-1555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 SE MORRISON ST APT 328
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-3193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-583-4245
-----------------------------------------------------
Fax | 503-419-6202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NATUROPATHIC DOCTOR
-----------------------------------------------------
Name | DR. MEGHAN ELLEN REVOIR BENNETT
-----------------------------------------------------
Credential | ND
-----------------------------------------------------
Telephone | 503-583-4245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 2062
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------