Provider Demographics
NPI:1407442338
Name:SISKIYOU VITAL MEDICINE LLC
Entity Type:Organization
Organization Name:SISKIYOU VITAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MCCLANE
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:541-210-5687
Mailing Address - Street 1:940 ELLENDALE DR # 102
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8216
Mailing Address - Country:US
Mailing Address - Phone:541-210-5687
Mailing Address - Fax:541-392-4962
Practice Address - Street 1:940 ELLENDALE DR # 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8216
Practice Address - Country:US
Practice Address - Phone:541-210-5687
Practice Address - Fax:541-392-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty