Provider Demographics
NPI:1215354741
Name:HAWTHORNE WELLNESS CENTER
Entity type:Organization
Organization Name:HAWTHORNE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-235-5484
Mailing Address - Street 1:3942 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5242
Mailing Address - Country:US
Mailing Address - Phone:503-235-5484
Mailing Address - Fax:503-235-3956
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:503-235-5484
Practice Address - Fax:503-235-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service