Provider Demographics
NPI:1538567847
Name:WILL HALLETT BODYWORK, INC
Entity type:Organization
Organization Name:WILL HALLETT BODYWORK, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:HALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-224-6800
Mailing Address - Street 1:511 SW 10TH AVE
Mailing Address - Street 2:STE 1108
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2732
Mailing Address - Country:US
Mailing Address - Phone:503-224-6800
Mailing Address - Fax:503-224-6800
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:STE 1108
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-224-6800
Practice Address - Fax:503-224-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18758305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service