Healthcare Provider Details

I. General information

NPI: 1669819652
Provider Name (Legal Business Name): COLUMBIA GORGE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 WEBBER ST
THE DALLES OR
97058-3749
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 541-769-0426
  • Fax: 541-769-0431
Mailing address:
  • Phone: 714-347-1010
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200860006CRNA
License Number StateOR

VIII. Authorized Official

Name: MR. DAVID C BULLOCK
Title or Position: PRESIDENT
Credential: CRNA
Phone: 714-347-1010