Healthcare Provider Details

I. General information

NPI: 1205791324
Provider Name (Legal Business Name): WILLAMETTE LIVING GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1466 SW 5TH PL
GRESHAM OR
97080-6828
US

IV. Provider business mailing address

1040 LAVONA DR NW
SALEM OR
97304-3744
US

V. Phone/Fax

Practice location:
  • Phone: 503-891-5648
  • Fax:
Mailing address:
  • Phone: 503-891-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP M HUBER
Title or Position: MANAGING MEMBER
Credential:
Phone: 503-891-5648