Healthcare Provider Details

I. General information

NPI: 1013098094
Provider Name (Legal Business Name): CG GROUP ASTORIA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 SE 12TH PL
WARRENTON OR
97146-9311
US

IV. Provider business mailing address

2185 SE 12TH PL
WARRENTON OR
97146-9311
US

V. Phone/Fax

Practice location:
  • Phone: 503-861-6240
  • Fax: 503-861-6358
Mailing address:
  • Phone: 503-861-6240
  • Fax: 503-861-6358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL W LARY
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-861-6244