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General NPI Number Information
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NPI Number | 1407442338
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Entity Type | Organization
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Legal Business Name | SISKIYOU VITAL MEDICINE LLC
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Dates
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Enumeration Date | 12/15/2020
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Last Update Date | 12/15/2020
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Provider Practice Location Address
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Address Line | 940 ELLENDALE DR # 102
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City | MEDFORD
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State | OR
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Zip | 97504-8216
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Country | US
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Telephone | 541-210-5687
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Fax | 541-392-4962
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Provider Business Mailing Address
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Address Line | 940 ELLENDALE DR # 102
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City | MEDFORD
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State | OR
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Zip | 97504-8216
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Country | US
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Telephone | 541-210-5687
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Fax | 541-392-4962
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | MR. GREGORY MCCLANE DUNCAN
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Credential | ND
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Telephone | 541-210-5687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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