Provider Demographics
NPI:1588131411
Name:MIND & BODY WELLNESS OF BEAVERTON
Entity type:Organization
Organization Name:MIND & BODY WELLNESS OF BEAVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-891-1389
Mailing Address - Street 1:4545 SW ANGEL AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2717
Mailing Address - Country:US
Mailing Address - Phone:503-891-1389
Mailing Address - Fax:
Practice Address - Street 1:4545 SW ANGEL AVE APT 108
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2717
Practice Address - Country:US
Practice Address - Phone:503-891-1389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500740983Medicaid
OR5857OtherSTATE CHIROPRACTIC LICENSE
ORR4317OtherLICENSE NUMBER