=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225568454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDSTAR VASCULAR ACCESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2017
-----------------------------------------------------
Last Update Date | 06/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2870 NE HOGAN DR STE E #205
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 150-351-6920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1871 SE IRONWOOD WAY
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97080-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 15035169205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DAVID ILNITSKIY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 503-516-9205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------