Provider Demographics
NPI:1366167629
Name:PORTLAND WELLNESS PROJECT
Entity type:Organization
Organization Name:PORTLAND WELLNESS PROJECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ILANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUREVICH
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-880-8452
Mailing Address - Street 1:3954 NE CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1005
Mailing Address - Country:US
Mailing Address - Phone:503-880-8452
Mailing Address - Fax:
Practice Address - Street 1:1901 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4436
Practice Address - Country:US
Practice Address - Phone:503-880-8452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1225218977OtherNPPES
OR1073941399OtherNPPES