Healthcare Provider Details

I. General information

NPI: 1124352877
Provider Name (Legal Business Name): WVP MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 12TH ST SE
SALEM OR
97302-2151
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 503-363-8047
  • Fax: 503-363-6571
Mailing address:
  • Phone: 503-371-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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