Organization
WILD EARTH WELLNESS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENNIFER MARIE BOOM LMT (OWNER)
(503) 310-2622
Entity
Organization
Contact information
Practice address
24850 SE STARK ST STE 200, GRESHAM, OR 97030-8320
(503) 310-2622
Mailing address
24850 SE STARK ST STE 200, GRESHAM, OR 97030-8320
(503) 310-2622
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
7615
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1164547634
NPI
—
Enumeration date
08/10/2017
Last updated
07/21/2022
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