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NPI Code Detail

MEDICARE: WVP MEDICAL GROUP, LLC

MEDICARE: WVP MEDICAL GROUP, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261Q00000XClinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1538535059
Entity Type Code : Organization
Provider Name (Legal Business Name) : WVP MEDICAL GROUP, LLC
Provider Business Mailing Address
First Line : 2995 RYAN DR SE STE 200
Second Line :
City : SALEM
State : OR
Zip : 97301-5157
Country : US
Telephone Number : 503-371-7701
Fax Number :
Provider Business Practice Location Address
First Line : 1430 MONMOUTH ST
Second Line :
City : INDEPENDENCE
State : OR
Zip : 97351-1127
Country : US
Telephone Number : 503-838-1133
Fax Number : 503-838-5138
Authorized Official
Title or Position : CFO
Name : MR. DEAN ANDRETTA
Credential :
Telephone Number : 503-371-7701
Provider Enumeration Date : 08/19/2015
Last Update Date : 04/17/2018

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