MEDICARE: SOUTHERN OREGON NEUROPSYCHOLOGICAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist
2	103G00000X	Clinical Neuropsychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588726939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN OREGON NEUROPSYCHOLOGICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	837 ALDER CREEK DR
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-8911
Country	:	US
Telephone Number	:	541-608-3878
Fax Number	:	541-608-3880

Provider Business Practice Location Address
First Line	:	837 ALDER CREEK DR
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504
Country	:	US
Telephone Number	:	541-608-3878
Fax Number	:	541-608-3880

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL R VILLANUEVA
Credential	:	PSYD
Telephone Number	:	541-608-3878

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/16/2018

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