Provider Demographics
NPI:1497319800
Name:GORGE VALLEY MEDICINE, LLC
Entity Type:Organization
Organization Name:GORGE VALLEY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-965-9164
Mailing Address - Street 1:517 BROWNS RD
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-2325
Mailing Address - Country:US
Mailing Address - Phone:541-965-9164
Mailing Address - Fax:
Practice Address - Street 1:1631 WOODS CT STE 103
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2916
Practice Address - Country:US
Practice Address - Phone:541-346-3880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty