Provider Demographics
NPI:1902291461
Name:ELISE WONG
Entity Type:Organization
Organization Name:ELISE WONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-477-5051
Mailing Address - Street 1:1110 SE ALDER ST
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2400
Mailing Address - Country:US
Mailing Address - Phone:503-477-5051
Mailing Address - Fax:
Practice Address - Street 1:1110 SE ALDER ST
Practice Address - Street 2:STE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2400
Practice Address - Country:US
Practice Address - Phone:503-477-5051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELISE WONG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center