# WELLINGTON PROVIDER GROUP, PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** WELLINGTON PROVIDER GROUP, PC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1619689957
- **Legal business name:** WELLINGTON PROVIDER GROUP, PC
- **Authorized official:** MARIELA BRAVO (CREDENTIALING TEAM LEAD)
- **Authorized official phone:** (831) 313-6799

## Contact information

- **Practice address:** 10260 SW GREENBURG RD FL 4, PORTLAND, OR 97223-5500
- **Practice address phone:** (859) 439-0400
- **Mailing address:** 535 WELLINGTON WAY STE 330, LEXINGTON, KY 40503-1331

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/19/2022
- **Last updated:** 12/19/2022