Healthcare Provider Details

I. General information

NPI: 1164814471
Provider Name (Legal Business Name): CELILO SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E 19TH ST STE 225
THE DALLES OR
97058-3388
US

IV. Provider business mailing address

1810 E 19TH ST STE 225
THE DALLES OR
97058-3388
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-6101
  • Fax: 541-296-0025
Mailing address:
  • Phone: 541-296-6101
  • Fax: 541-296-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KARI GUTZLER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 541-296-6101