Healthcare Provider Details

I. General information

NPI: 1265131775
Provider Name (Legal Business Name): MARTIN KENNETH GAITER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 MLK JR BLVD
EUGENE OR
97401-5824
US

IV. Provider business mailing address

2073 OLYMPIC ST
SPRINGFIELD OR
97477-3413
US

V. Phone/Fax

Practice location:
  • Phone: 541-682-3550
  • Fax: 541-682-9861
Mailing address:
  • Phone: 541-682-3550
  • Fax: 541-682-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number108291
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2761438
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREGON DRIVER LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: