Provider Demographics
NPI:1811648579
Name:TINA CAPUTO
Entity type:Organization
Organization Name:TINA CAPUTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE GADZALA
Authorized Official - Last Name:CAPTUO
Authorized Official - Suffix:
Authorized Official - Credentials:L AC
Authorized Official - Phone:858-204-9661
Mailing Address - Street 1:22400 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22400 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2656
Practice Address - Country:US
Practice Address - Phone:858-204-9661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TINA CAPUTO LMT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center