1558726273 NPI number — SHIFTING SANDS HOLISTIC HEALING LLC

Table of content: (NPI 1558726273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558726273 NPI number — SHIFTING SANDS HOLISTIC HEALING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIFTING SANDS HOLISTIC HEALING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558726273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1271 SE LEANDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97123-5199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-882-8081
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 W MAIN ST STE A100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123-3985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-882-8081
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MONTERA
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
503-882-8081

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  8313 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8313 . This is a "STATE LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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