MEDICARE: WELLNESS WAY BEAVERTON 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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1780211391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS WAY BEAVERTON LLC

Provider Business Mailing Address
First Line	:	12655 SW CENTER ST STE 145
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-1864
Country	:	US
Telephone Number	:	971-727-8965
Fax Number	:

Provider Business Practice Location Address
First Line	:	12655 SW CENTER ST STE 145
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-1864
Country	:	US
Telephone Number	:	971-727-8965
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEPPHINE TILDEN
Credential	:	DC
Telephone Number	:	971-727-8965

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/24/2020

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Directions to “WELLNESS WAY BEAVERTON LLC ” Practice Location

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