Provider Demographics
NPI:1063713717
Name:GLADSTONE COMMUNITY CLINIC
Entity type:Organization
Organization Name:GLADSTONE COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:R.N.
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-850-4472
Mailing Address - Street 1:18911 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18911 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1630
Practice Address - Country:US
Practice Address - Phone:503-850-4472
Practice Address - Fax:503-850-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200243005RN261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health