Provider Demographics
NPI:1710642756
Name:MARINO, GAVON
Entity Type:Individual
Prefix:MR
First Name:GAVON
Middle Name:
Last Name:MARINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91150 N COBURG INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9512
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:
Practice Address - Street 1:91150 N COBURG INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9512
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)