Provider Demographics
NPI:1194069450
Name:WILLAMETTE VALLEY WELLNESS LLC
Entity type:Organization
Organization Name:WILLAMETTE VALLEY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOLFRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-689-1216
Mailing Address - Street 1:4356 COMMERCIAL STREET SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-689-1216
Mailing Address - Fax:503-689-1520
Practice Address - Street 1:4356 COMMERCIAL STREET SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-689-1216
Practice Address - Fax:503-689-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3989111N00000X
OR13553225700000X
OR17108225700000X
OR14327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty