Healthcare Provider Details

I. General information

NPI: 1811648579
Provider Name (Legal Business Name): TINA CAPUTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 858-204-9661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: CHRISTINA MARIE GADZALA CAPTUO
Title or Position: OWNER
Credential: L. AC.
Phone: 858-204-9661