Healthcare Provider Details

I. General information

NPI: 1407442338
Provider Name (Legal Business Name): SISKIYOU VITAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 ELLENDALE DR # 102
MEDFORD OR
97504-8216
US

IV. Provider business mailing address

940 ELLENDALE DR # 102
MEDFORD OR
97504-8216
US

V. Phone/Fax

Practice location:
  • Phone: 541-210-5687
  • Fax: 541-392-4962
Mailing address:
  • Phone: 541-210-5687
  • Fax: 541-392-4962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY MCCLANE DUNCAN
Title or Position: OWNER/MEMBER
Credential: ND
Phone: 541-210-5687