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General NPI Number Information
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NPI Number | 1194069450
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Entity Type | Organization
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Legal Business Name | WILLAMETTE VALLEY WELLNESS LLC
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Dates
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Enumeration Date | 11/26/2012
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Last Update Date | 11/26/2012
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Provider Practice Location Address
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Address Line | 4356 COMMERCIAL STREET SE
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City | SALEM
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State | OR
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Zip | 97302
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Country | US
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Telephone | 503-689-1216
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Fax | 503-689-1520
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Provider Business Mailing Address
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Address Line | 4356 COMMERCIAL STREET SE
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City | SALEM
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State | OR
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Zip | 97302
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Country | US
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Telephone | 503-689-1216
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Fax | 503-689-1520
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOSHUA R WOLFRAM
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Credential | DC
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Telephone | 503-689-1216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 13553
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 17108
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 14327
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3989
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License Number State | OR
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