Provider Demographics
NPI:1427293349
Name:VISANA WELLNESS, LLC
Entity type:Organization
Organization Name:VISANA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:KATHER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-251-1010
Mailing Address - Street 1:PO BOX 6945
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0353
Mailing Address - Country:US
Mailing Address - Phone:541-469-9100
Mailing Address - Fax:541-469-9200
Practice Address - Street 1:603 HEMLOCK STREET
Practice Address - Street 2:3B
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9999
Practice Address - Country:US
Practice Address - Phone:541-469-9100
Practice Address - Fax:541-469-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250089NP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care