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General NPI Number Information
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NPI Number | 1528220936
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Entity Type | Organization
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Legal Business Name | WILLAMETTE FALLS PEDIATRIC GROUP, PC
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 200 SOUTH HAZEL DELL WAY SUITE 202
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City | CANBY
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State | OR
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Zip | 97013
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Country | US
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Telephone | 503-266-8500
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Fax | 503-266-8585
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Provider Business Mailing Address
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Address Line | 1510 DIVISION ST SUITE 280
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City | OREGON CITY
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State | OR
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Zip | 97045-1581
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Country | US
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Telephone | 503-905-3400
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Fax | 503-905-3399
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. CHRISTINA MARIE GRUCELLA
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Credential | M.D.
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Telephone | 503-905-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 1292945-0
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License Number State | OR
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