Healthcare Provider Details

I. General information

NPI: 1467303735
Provider Name (Legal Business Name): GUSTAVO ADRIAN ENRIQUEZ URIBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SE D ST
MADRAS OR
97741-1699
US

IV. Provider business mailing address

850 SW 4TH ST
MADRAS OR
97741-9628
US

V. Phone/Fax

Practice location:
  • Phone: 541-615-2650
  • Fax: 541-777-6169
Mailing address:
  • Phone: 541-475-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26-01-11771
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: