Provider Demographics
NPI:1457592271
Name:CLINICA MEDICAL NUESTRA SENORA DE GUADALUPE
Entity Type:Organization
Organization Name:CLINICA MEDICAL NUESTRA SENORA DE GUADALUPE
Other - Org Name:GUADALUPE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATTIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-364-5818
Mailing Address - Street 1:1495 LIBERTY ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-6431
Mailing Address - Country:US
Mailing Address - Phone:503-364-5818
Mailing Address - Fax:503-364-2484
Practice Address - Street 1:1495 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6431
Practice Address - Country:US
Practice Address - Phone:503-364-5818
Practice Address - Fax:503-364-2484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center