Basic Information
| Provider Information | |||||||||
| NPI: | 1063713717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLADSTONE COMMUNITY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18911 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271630 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18911 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038504472 | ||||||||
| FaxNumber: | 5038504473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2010 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | HANNAH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | R.N. | ||||||||
| AuthorizedOfficialTelephone: | 5038504472 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 200243005RN | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.