Healthcare Provider Details

I. General information

NPI: 1194069450
Provider Name (Legal Business Name): WILLAMETTE VALLEY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4356 COMMERCIAL STREET SE
SALEM OR
97302
US

IV. Provider business mailing address

4356 COMMERCIAL STREET SE
SALEM OR
97302
US

V. Phone/Fax

Practice location:
  • Phone: 503-689-1216
  • Fax: 503-689-1520
Mailing address:
  • Phone: 503-689-1216
  • Fax: 503-689-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3989
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13553
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17108
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14327
License Number StateOR

VIII. Authorized Official

Name: DR. JOSHUA R WOLFRAM
Title or Position: OWNER
Credential: DC
Phone: 503-689-1216