Healthcare Provider Details

I. General information

NPI: 1306771373
Provider Name (Legal Business Name): THE VILLA MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15203 NE 72ND AVE
VANCOUVER WA
98686-1929
US

IV. Provider business mailing address

15203 NE 72ND AVE
VANCOUVER WA
98686-1929
US

V. Phone/Fax

Practice location:
  • Phone: 360-209-4449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL ROA-TREBOL
Title or Position: OWNER
Credential:
Phone: 541-720-8789