Healthcare Provider Details

I. General information

NPI: 1750684767
Provider Name (Legal Business Name): WVP MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 RIVER RD N
KEIZER OR
97303-5371
US

IV. Provider business mailing address

2995 RYAN DR SE STE 200
SALEM OR
97301-5157
US

V. Phone/Fax

Practice location:
  • Phone: 503-393-2533
  • Fax: 503-393-5978
Mailing address:
  • Phone: 503-371-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier288533
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MR. DEAN ANDRETTA
Title or Position: CFO
Credential:
Phone: 503-371-7701