Healthcare Provider Details

I. General information

NPI: 1669727160
Provider Name (Legal Business Name): JOHN WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MULLINS DR SUITE A-1
LEBANON OR
97355-3982
US

IV. Provider business mailing address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-6920
  • Fax: 541-451-6924
Mailing address:
  • Phone: 541-766-6835
  • Fax: 541-766-6186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: