Healthcare Provider Details

I. General information

NPI: 1003914243
Provider Name (Legal Business Name): STARK STREET PLAZA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST SUITE 310
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

24076 SE STARK ST SUITE 310
GRESHAM OR
97030-3373
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-6510
  • Fax: 503-492-6502
Mailing address:
  • Phone: 503-492-6510
  • Fax: 503-492-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAMMAI ROCKOVE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 503-492-6510