Provider Demographics
NPI:1023629896
Name:TOES IN THE WATER WELLNESS LLC
Entity type:Organization
Organization Name:TOES IN THE WATER WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-454-0782
Mailing Address - Street 1:11804 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9308
Mailing Address - Country:US
Mailing Address - Phone:503-454-0782
Mailing Address - Fax:866-577-6285
Practice Address - Street 1:11804 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9308
Practice Address - Country:US
Practice Address - Phone:503-454-0782
Practice Address - Fax:866-577-6285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4111979Medicaid