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General NPI Number Information
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NPI Number | 1356388078
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Entity Type | Organization
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Legal Business Name | WALLOWA MOUNTAIN MEDICAL
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Dates
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Enumeration Date | 06/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 100 NORTH EAST STREET
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City | JOSEPH
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State | OR
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Zip | 97846-1038
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Country | US
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Telephone | 541-432-7777
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Fax | 541-432-7170
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Provider Business Mailing Address
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Address Line | PO BOX 1038 100 N. EAST STREET
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City | JOSEPH
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State | OR
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Zip | 97846-1038
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Country | US
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Telephone | 541-432-7777
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Fax | 541-432-7170
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LESLIE D. PACE
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Credential |
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Telephone | 541-432-0197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD16299
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License Number State | OR
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