Provider Demographics
NPI:1194100255
Name:SAKURA RECOVERY AND WELLNESS, LLC.
Entity type:Organization
Organization Name:SAKURA RECOVERY AND WELLNESS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER/OWNE
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:310-701-7242
Mailing Address - Street 1:1675 SW MARLOW AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5105
Mailing Address - Country:US
Mailing Address - Phone:310-701-7242
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 315
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5105
Practice Address - Country:US
Practice Address - Phone:310-701-7242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201403432NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty