Provider Demographics
NPI:1093952996
Name:WALLOWA VALLEY CENTER FOR WELLNESS
Entity Type:Organization
Organization Name:WALLOWA VALLEY CENTER FOR WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KLIEWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-426-4524
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0268
Mailing Address - Country:US
Mailing Address - Phone:541-426-4524
Mailing Address - Fax:541-426-3035
Practice Address - Street 1:207 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1203
Practice Address - Country:US
Practice Address - Phone:541-426-4524
Practice Address - Fax:541-426-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210511Medicaid