Provider Demographics
NPI:1598024671
Name:ANDALUZ BIRTH CENTER
Entity type:Organization
Organization Name:ANDALUZ BIRTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLARDO
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LDM
Authorized Official - Phone:503-885-0228
Mailing Address - Street 1:3323 SW NAITO PKWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4672
Mailing Address - Country:US
Mailing Address - Phone:503-885-0228
Mailing Address - Fax:503-274-0607
Practice Address - Street 1:3323 SW NAITO PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4672
Practice Address - Country:US
Practice Address - Phone:503-885-0228
Practice Address - Fax:503-274-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-1596261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297219Medicaid