1992172977 NPI number — WHITTAKER WELLNESS AND PERFORMANCE CENTER

Table of content: (NPI 1992172977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992172977 NPI number — WHITTAKER WELLNESS AND PERFORMANCE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITTAKER WELLNESS AND PERFORMANCE CENTER
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:
1992172977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 SW BROADWAY
Provider Second Line Business Mailing Address:
SUITE 1210
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97205-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-224-3898
Provider Business Mailing Address Fax Number:
503-241-4079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 SW BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 1210
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97205-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-3898
Provider Business Practice Location Address Fax Number:
503-241-4079
Provider Enumeration Date:
08/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WHITTAKER
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
503-224-3898

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  3181 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: 1530 , 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)





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