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General NPI Number Information
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NPI Number | 1659891455
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Entity Type | Organization
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Legal Business Name | WELLER NEUROLOGY LLC
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Dates
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Enumeration Date | 06/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 24900 SE STARK ST STE 211
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City | GRESHAM
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State | OR
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Zip | 97030-3382
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Country | US
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Telephone | 503-669-0435
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Fax | 503-618-1859
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Provider Business Mailing Address
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Address Line | 24900 SE STARK ST STE 211
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City | GRESHAM
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State | OR
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Zip | 97030-3382
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Country | US
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Telephone | 503-669-0435
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Fax | 503-618-1859
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIRK L WELLER
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Credential | MD
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Telephone | 503-669-0453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | MD17310
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License Number State | OR
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