=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972749604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALIVE & WELL HEALING ARTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2008
-----------------------------------------------------
Last Update Date | 12/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9900 SW WILSHIRE ST # 190-D
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-484-8647
-----------------------------------------------------
Fax | 503-297-3827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9900 SW WILSHIRE ST # 190-D
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-484-8647
-----------------------------------------------------
Fax | 503-297-3827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAIVATI BHARADVAJ
-----------------------------------------------------
Credential | ND
-----------------------------------------------------
Telephone | 503-484-8647
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 1297
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------