Provider Demographics
NPI:1356084271
Name:WILLOW ROOT MEDICINE, LLC
Entity type:Organization
Organization Name:WILLOW ROOT MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THORN
Authorized Official - Middle Name:AM
Authorized Official - Last Name:WILLOW
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-309-0376
Mailing Address - Street 1:16444 SE 135TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8932
Mailing Address - Country:US
Mailing Address - Phone:503-309-0376
Mailing Address - Fax:
Practice Address - Street 1:16444 SE 135TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8932
Practice Address - Country:US
Practice Address - Phone:503-309-0376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service