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General NPI Number Information
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NPI Number | 1861650301
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 05/31/2008
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Last Update Date | 05/31/2008
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Provider Practice Location Address
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Address Line | 2343 SE 44TH AVE
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City | PORTLAND
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State | OR
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Zip | 97215-3721
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Country | US
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Telephone | 503-997-7181
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Fax |
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Provider Business Mailing Address
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Address Line | 2343 SE 44TH AVE
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City | PORTLAND
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State | OR
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Zip | 97215-3721
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED ACUPUNTURIST
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Name | RICHARD BRAD MCCONNELL
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Credential | LAC
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Telephone | 503-997-7181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | AC00850
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License Number State | OR
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