Healthcare Provider Details

I. General information

NPI: 1376242966
Provider Name (Legal Business Name): MEDICINAL INNOVATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 STATE ST STE 1100
SALEM OR
97301-3538
US

IV. Provider business mailing address

388 STATE ST STE 1100
SALEM OR
97301-3538
US

V. Phone/Fax

Practice location:
  • Phone: 503-908-6050
  • Fax:
Mailing address:
  • Phone: 503-908-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LESLIE ANN DRAPIZA
Title or Position: OWNER
Credential: MD
Phone: 503-908-6050