MEDICARE: SOUL PUSH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1598658387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL PUSH LLC

Provider Business Mailing Address
First Line	:	1038 BROADWAY ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-1276
Country	:	US
Telephone Number	:	605-824-8659
Fax Number	:

Provider Business Practice Location Address
First Line	:	1038 BROADWAY ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-1276
Country	:	US
Telephone Number	:	605-824-8659
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALI FARHAN
Credential	:
Telephone Number	:	605-824-8659

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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Directions to “SOUL PUSH LLC ” Practice Location

Language	Start Address	Practice Location

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