Provider Demographics
NPI:1730902941
Name:WYNN STREET LLC
Entity type:Organization
Organization Name:WYNN STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-303-9360
Mailing Address - Street 1:10445 SW CANYON RD STE 114
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1913
Mailing Address - Country:US
Mailing Address - Phone:971-303-9360
Mailing Address - Fax:
Practice Address - Street 1:10445 SW CANYON RD STE 114
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1913
Practice Address - Country:US
Practice Address - Phone:971-303-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELECTRO GLOW ELECTROLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-05
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty