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
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1831504968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WVP MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2485 12TH ST. SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-0000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2485 12TH ST. SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-0000
Country	:	US
Telephone Number	:	503-363-8047
Fax Number	:	503-363-6571

Authorized Official
Title or Position	:	CFO
Name	:	MR. DEAN ANDRETTA
Credential	:
Telephone Number	:	503-371-7701

Provider Enumeration Date	:	06/27/2014
Last Update Date	:	06/27/2014

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