Healthcare Provider Details

I. General information

NPI: 1124396544
Provider Name (Legal Business Name): VALLEY PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S PACIFIC HWY
TALENT OR
97540-6649
US

IV. Provider business mailing address

280 S PACIFIC HWY
TALENT OR
97540-6649
US

V. Phone/Fax

Practice location:
  • Phone: 541-512-4771
  • Fax: 541-512-0880
Mailing address:
  • Phone: 541-512-4771
  • Fax: 541-512-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS ALLISON TRACY
Title or Position: PHYSICIAN
Credential: DO
Phone: 304-520-6644