MEDICARE: WILD FOLIAGE MASSAGE & BOTANICALS 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1811841687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD FOLIAGE MASSAGE & BOTANICALS LLC

Provider Business Mailing Address
First Line	:	4607 SE 43RD AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-4103
Country	:	US
Telephone Number	:	512-809-3498
Fax Number	:

Provider Business Practice Location Address
First Line	:	2632 SE 25TH AVE STE G
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1285
Country	:	US
Telephone Number	:	512-809-3498
Fax Number	:

Authorized Official
Title or Position	:	LMT
Name	:	REYNA KOHL
Credential	:	LMT
Telephone Number	:	512-809-3498

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	02/26/2026

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