Provider Demographics
NPI:1366620676
Name:AUGUSTINE GONZALES
Entity type:Organization
Organization Name:AUGUSTINE GONZALES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-537-9600
Mailing Address - Street 1:2880 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1310
Mailing Address - Country:US
Mailing Address - Phone:503-537-9600
Mailing Address - Fax:503-537-0105
Practice Address - Street 1:2880 HAYES ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1310
Practice Address - Country:US
Practice Address - Phone:503-537-9600
Practice Address - Fax:503-537-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care