Provider Demographics
NPI:1053836247
Name:PORTLAND OPTIMAL WELLNESS, LLC
Entity type:Organization
Organization Name:PORTLAND OPTIMAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-686-4448
Mailing Address - Street 1:14511 WESTLAKE DR STE 148
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14511 WESTLAKE DR STE 148
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7773
Practice Address - Country:US
Practice Address - Phone:503-941-5351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty