Provider Demographics
NPI:1164780060
Name:WVP MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:WVP FLAMING MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-623-8376
Mailing Address - Street 1:2995 RYAN DR SE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5157
Mailing Address - Country:US
Mailing Address - Phone:503-371-7701
Mailing Address - Fax:
Practice Address - Street 1:1000 SE UGLOW AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2645
Practice Address - Country:US
Practice Address - Phone:503-623-8376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WVP MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-27
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO10396261QP2300X
ORDO15134261QP2300X
ORPA153023261QP2300X
ORPA00266261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288533Medicaid