Healthcare Provider Details

I. General information

NPI: 1669168779
Provider Name (Legal Business Name): SERGIO ENRIQUE ORTEGA CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SERGIO E ORTEGA CHW

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

1220 SW 25TH ST
TROUTDALE OR
97060-1741
US

V. Phone/Fax

Practice location:
  • Phone: 971-865-1188
  • Fax: 503-988-5185
Mailing address:
  • Phone: 503-701-1210
  • Fax: 503-988-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberTHW000108654
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: