MEDICARE: K. G. GAUNTT D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	DP00197	OR

General Provider Information

NPI Number	:	1871739482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K. G. GAUNTT D.P.M.

Provider Business Mailing Address
First Line	:	200 NE 4TH AVENUE
Second Line	:
City	:	HILLSBORO
State	:	OR
Zip	:	97124-3127
Country	:	US
Telephone Number	:	503-538-0466
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 VILLA RD
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-1853
Country	:	US
Telephone Number	:	503-538-0466
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNTS MANAGER
Name	:	MRS. GAIL SHEPHERD
Credential	:
Telephone Number	:	503-538-0466

Provider Enumeration Date	:	01/02/2009
Last Update Date	:	01/02/2009

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