Provider Demographics
NPI:1760998355
Name:WELL LIFE FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:WELL LIFE FAMILY MEDICINE, LLC
Other - Org Name:WILLAMETTE VALLEY WEIGHT LOSS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:971-301-4411
Mailing Address - Street 1:1174 CORNUCOPIA ST NW STE 240
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3193
Mailing Address - Country:US
Mailing Address - Phone:971-301-4411
Mailing Address - Fax:971-999-7006
Practice Address - Street 1:1174 CORNUCOPIA ST NW STE 240
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304
Practice Address - Country:US
Practice Address - Phone:971-301-4411
Practice Address - Fax:971-999-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3012261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694138Medicaid