Provider Demographics
NPI:1619717170
Name:LAVENDER MOON WELLNESS LLC
Entity type:Organization
Organization Name:LAVENDER MOON WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:M PAQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-960-3366
Mailing Address - Street 1:2933 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1760
Mailing Address - Country:US
Mailing Address - Phone:503-960-3366
Mailing Address - Fax:
Practice Address - Street 1:2933 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1760
Practice Address - Country:US
Practice Address - Phone:503-960-3366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty