Healthcare Provider Details

I. General information

NPI: 1497851893
Provider Name (Legal Business Name): CHINIKO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 14TH AVE SE
ALBANY OR
97322
US

IV. Provider business mailing address

2700 14TH AVE SE
ALBANY OR
97322
US

V. Phone/Fax

Practice location:
  • Phone: 541-928-1667
  • Fax: 541-928-1817
Mailing address:
  • Phone: 541-928-1667
  • Fax: 541-928-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number071514
License Number StateOR

VIII. Authorized Official

Name: DARRELL GENSTLER
Title or Position: OWNER
Credential: MD
Phone: 541-928-1667