Provider Demographics
NPI:1811487457
Name:GUZMAN, ROBERTO EMMANUEL
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:EMMANUEL
Last Name:GUZMAN
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 1:3030 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4528
Mailing Address - Country:US
Mailing Address - Phone:503-373-3762
Mailing Address - Fax:
Practice Address - Street 1:3040 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4528
Practice Address - Country:US
Practice Address - Phone:503-373-3762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-6002307Medicaid