Provider Demographics
NPI:1386785772
Name:METAMORPHOSIS CENTER FOR HOLISTIC MEDICINE, LLC
Entity type:Organization
Organization Name:METAMORPHOSIS CENTER FOR HOLISTIC MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:GLASSER
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-234-1531
Mailing Address - Street 1:5909 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1470
Mailing Address - Country:US
Mailing Address - Phone:503-234-1531
Mailing Address - Fax:503-234-2367
Practice Address - Street 1:5909 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1470
Practice Address - Country:US
Practice Address - Phone:503-234-1531
Practice Address - Fax:503-234-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12762261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC94341Medicare UPIN