Healthcare Provider Details

I. General information

NPI: 1366620676
Provider Name (Legal Business Name): AUGUSTINE GONZALES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 HAYES ST
NEWBERG OR
97132-1310
US

IV. Provider business mailing address

2880 HAYES ST
NEWBERG OR
97132-1310
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-9600
  • Fax: 503-537-0105
Mailing address:
  • Phone: 503-537-9600
  • Fax: 503-537-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AUGUSTINE GONZALES
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 503-537-9600