Provider Demographics
NPI:1295206316
Name:GENTNER, SARA L
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:L
Last Name:GENTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LELE
Other - Middle Name:
Other - Last Name:HEARTLOOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6425 SE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-5331
Mailing Address - Country:US
Mailing Address - Phone:503-896-8681
Mailing Address - Fax:
Practice Address - Street 1:2526 NE 15TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4222
Practice Address - Country:US
Practice Address - Phone:503-896-8681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist