Provider Demographics
NPI:1134012180
Name:MODA WELLNESS LLC
Entity type:Organization
Organization Name:MODA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF HUMAN RESOURCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-702-3164
Mailing Address - Street 1:5331 S MACADAM AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3863
Mailing Address - Country:US
Mailing Address - Phone:503-243-3967
Mailing Address - Fax:503-243-3895
Practice Address - Street 1:5331 S MACADAM AVE STE 260
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3863
Practice Address - Country:US
Practice Address - Phone:503-243-3967
Practice Address - Fax:503-243-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty