# WILLAMETTE COMMUNITY MEDICAL GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MEDVANTX, INC.
- **Other names:** OMG Thurston Medical Group
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1104062371
- **Legal business name:** MEDVANTX, INC.
- **Authorized official:** KENNY HEINE (DIRECTOR OF OPERATIONS)
- **Authorized official phone:** (858) 625-2990

## Contact information

- **Practice address:** 5781 MAIN ST, SPRINGFIELD, OR 97478-5426
- **Practice address phone:** (541) 284-1694
- **Mailing address:** 5810 NANCY RIDGE DR, 100, SAN DIEGO, CA 92121-2834

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | MD15590 | OR | Yes |

## Other

- **Enumeration date:** 12/18/2008
- **Last updated:** 12/18/2008