Healthcare Provider Details

I. General information

NPI: 1598024671
Provider Name (Legal Business Name): ANDALUZ BIRTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3323 SW NAITO PKWY
PORTLAND OR
97239-4672
US

IV. Provider business mailing address

3323 SW NAITO PKWY
PORTLAND OR
97239-4672
US

V. Phone/Fax

Practice location:
  • Phone: 503-885-0228
  • Fax: 503-274-0607
Mailing address:
  • Phone: 503-885-0228
  • Fax: 503-274-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number07-1596
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier297219
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: JENNIFER S. GALLARDO
Title or Position: OWNER / DIRECTOR
Credential: CPM, LDM
Phone: 503-885-0228