Basic Information
| Provider Information | |||||||||
| NPI: | 1659556462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLAMETTE COMMUNITY MEDICAL GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GARDEN WAY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | ATTN: DEBBIE BREWER | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657626 | ||||||||
| FaxNumber: | 6154653007 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S GARDEN WAY | ||||||||
| Address2: | STE. 350 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417466816 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILLAMETTE COMMUNITY MEDICAL GROUP LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1659556462 | 01 | OR | NPI | OTHER |