Healthcare Provider Details

I. General information

NPI: 1649612698
Provider Name (Legal Business Name): WILLAMETTE PROCEDURE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 8TH AVE STE 212
WEST LINN OR
97068-4657
US

IV. Provider business mailing address

2020 8TH AVE STE 212
WEST LINN OR
97068-4657
US

V. Phone/Fax

Practice location:
  • Phone: 541-488-2101
  • Fax: 541-488-5885
Mailing address:
  • Phone: 541-488-2101
  • Fax: 541-488-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateOR

VIII. Authorized Official

Name: GREG GULLO
Title or Position: OWNER
Credential: MD
Phone: 541-488-2101