Healthcare Provider Details

I. General information

NPI: 1336073980
Provider Name (Legal Business Name): ROBERTO GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3785 SW 5TH DR
GRESHAM OR
97030-6419
US

IV. Provider business mailing address

3785 SW 5TH DR
GRESHAM OR
97030-6419
US

V. Phone/Fax

Practice location:
  • Phone: 619-678-3061
  • Fax: 971-274-2157
Mailing address:
  • Phone: 619-678-3061
  • Fax: 971-274-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number11627
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: