Healthcare Provider Details

I. General information

NPI: 1013546985
Provider Name (Legal Business Name): G STREET INTEGRATED HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/25/2021
Certification Date: 04/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 G ST
SPRINGFIELD OR
97477-4113
US

IV. Provider business mailing address

PO BOX 163
SPRINGFIELD OR
97477-0024
US

V. Phone/Fax

Practice location:
  • Phone: 541-735-9420
  • Fax: 541-747-9420
Mailing address:
  • Phone: 541-735-9420
  • Fax: 541-747-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER OCKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-735-9421