Provider Demographics
NPI:1285327635
Name:ROGUE VALLEY PAIN PHYSICAL & REGENERATIVE MEDICINE LLC
Entity type:Organization
Organization Name:ROGUE VALLEY PAIN PHYSICAL & REGENERATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WRUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-250-1166
Mailing Address - Street 1:4951 GRIFFIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-9586
Mailing Address - Country:US
Mailing Address - Phone:541-200-0924
Mailing Address - Fax:541-200-0929
Practice Address - Street 1:845 ALDER CREEK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8900
Practice Address - Country:US
Practice Address - Phone:541-200-0924
Practice Address - Fax:541-200-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty