Healthcare Provider Details

I. General information

NPI: 1255693313
Provider Name (Legal Business Name): GUTIERREZ HOLISTIC FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 DONALD ST SUITE 110
EUGENE OR
97405-4753
US

IV. Provider business mailing address

3575 DONALD ST SUITE 110 A & B
EUGENE OR
97405-4753
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-5907
  • Fax: 154-131-9722
Mailing address:
  • Phone: 458-205-5907
  • Fax: 154-131-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberDO152080
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ORESTES GUTIERREZ
Title or Position: FAMILY PHYSICIAN
Credential: D.O.
Phone: 541-232-5627