1598106692 NPI number — HEAL GROW THRIVE MEDICINE LLC

Table of content: (NPI 1598106692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598106692 NPI number — HEAL GROW THRIVE MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEAL GROW THRIVE MEDICINE 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:
HEAL GROW THRIVE ACUPUNCTURE LLC
Provider Other Organization Name Type Code:
4
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:
1598106692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 SW DISK DRIVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-639-8911
Provider Business Mailing Address Fax Number:
541-633-7962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 SW DISK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-639-8911
Provider Business Practice Location Address Fax Number:
541-633-7962
Provider Enumeration Date:
07/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOURLAND
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
ILEANA
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
541-639-8911

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC153140 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 175F00000X , with the licence number: 4026 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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