Healthcare Provider Details

I. General information

NPI: 1649096785
Provider Name (Legal Business Name): LUIS ENRIQUE GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 MOUNT HOOD AVE
WOODBURN OR
97071
US

IV. Provider business mailing address

1475 MOUNT HOOD AVE
WOODBURN OR
97071-9099
US

V. Phone/Fax

Practice location:
  • Phone: 503-874-2451
  • Fax: 503-982-4599
Mailing address:
  • Phone: 503-874-2451
  • Fax: 503-982-4599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberTHW000108251
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: