Healthcare Provider Details

I. General information

NPI: 1124198999
Provider Name (Legal Business Name): VA SOUTHERN OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

839 N MAIN ST
ASHLAND OR
97520-1713
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone: 541-261-8349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: WOLFGANG LAURENCE AGOTTA
Title or Position: DUAL-DIAGNOSIS THERAPIST
Credential:
Phone: 541-826-2111