Healthcare Provider Details

I. General information

NPI: 1710510094
Provider Name (Legal Business Name): GRESHAM FAMILY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BLANKENSHIP RD STE 350
WEST LINN OR
97068-4182
US

IV. Provider business mailing address

PO BOX 91
WEST LINN OR
97068-0091
US

V. Phone/Fax

Practice location:
  • Phone: 503-213-6600
  • Fax: 971-350-7350
Mailing address:
  • Phone: 503-213-6600
  • Fax: 971-350-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH HAINES
Title or Position: OWNER
Credential:
Phone: 503-213-6600