Provider Demographics
NPI:1538446315
Name:SOUTHERN OREGON WELLNESS CLINIC, LLC
Entity type:Organization
Organization Name:SOUTHERN OREGON WELLNESS CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-200-2242
Mailing Address - Street 1:1744 E MCANDREWS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-973-2551
Mailing Address - Fax:541-973-2835
Practice Address - Street 1:2921 DOCTORS PARK DR STE B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8127
Practice Address - Country:US
Practice Address - Phone:541-200-2263
Practice Address - Fax:541-973-2835
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN OREGON WELLNESS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-08
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care