Healthcare Provider Details

I. General information

NPI: 1225568454
Provider Name (Legal Business Name): GOLDSTAR VASCULAR ACCESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 NE HOGAN DR STE E #205
GRESHAM OR
97030
US

IV. Provider business mailing address

1871 SE IRONWOOD WAY
GRESHAM OR
97080-3002
US

V. Phone/Fax

Practice location:
  • Phone: 150-351-6920
  • Fax:
Mailing address:
  • Phone: 15035169205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID ILNITSKIY
Title or Position: PRESIDENT
Credential: RN
Phone: 503-516-9205