Provider Demographics
NPI:1316236847
Name:WHOLE LIFE VITALITY
Entity type:Organization
Organization Name:WHOLE LIFE VITALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIBRAN
Authorized Official - Middle Name:KEKOA
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-482-9092
Mailing Address - Street 1:4110 SE HAWTHORNE BLVD # 178
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5246
Mailing Address - Country:US
Mailing Address - Phone:503-482-9092
Mailing Address - Fax:503-715-5789
Practice Address - Street 1:3942 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5242
Practice Address - Country:US
Practice Address - Phone:503-208-4546
Practice Address - Fax:503-715-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63999099261Q00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center