Provider Demographics
NPI:1518225242
Name:WVP MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:WVP MISSION STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-7701
Mailing Address - Street 1:1155 MISSION ST SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6228
Mailing Address - Country:US
Mailing Address - Phone:503-362-6304
Mailing Address - Fax:
Practice Address - Street 1:1155 MISSION ST SE
Practice Address - Street 2:SUITE 205
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6228
Practice Address - Country:US
Practice Address - Phone:503-362-6304
Practice Address - Fax:503-362-5570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY IPA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-01
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care