Individual
MCKENZIE VILLANUEVA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
18 MYRTLE ST, MEDFORD, OR 97504-7338
(541) 301-0522
Mailing address
18 MYRTLE ST, MEDFORD, OR 97504-7338
(541) 301-0522
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
BAP-TA-10200933
—
Other
Enumeration date
06/25/2020
Last updated
06/25/2020
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