Provider Demographics
NPI:1831504968
Name:WVP MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WVP MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-7701
Mailing Address - Street 1:2485 12TH ST. SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2485 12TH ST. SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-0000
Practice Address - Country:US
Practice Address - Phone:503-363-8047
Practice Address - Fax:503-363-6571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID VALLEY IPA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center