Provider Demographics
NPI:1720012339
Name:VENTANA WELLNESS, PC
Entity Type:Organization
Organization Name:VENTANA WELLNESS, PC
Other - Org Name:SOUTHERN OREGON HEALTH AND WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:NOODLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-773-9772
Mailing Address - Street 1:3156 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-773-9772
Mailing Address - Fax:541-773-1113
Practice Address - Street 1:3156 STATE STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06-00024661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287179Medicaid
ORR111470Medicare PIN
ORR111470Medicare UPIN