1376169581 NPI number — GABRIELLA SOLITA MARINCOVICH-MALLARES

Table of content: GABRIELLA SOLITA MARINCOVICH-MALLARES (NPI 1376169581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376169581 NPI number — GABRIELLA SOLITA MARINCOVICH-MALLARES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARINCOVICH-MALLARES
Provider First Name:
GABRIELLA
Provider Middle Name:
SOLITA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376169581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 N HIGHWAY 101 STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97146-9371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-325-5722
Provider Business Mailing Address Fax Number:
503-861-2043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3194 MARINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-325-5722
Provider Business Practice Location Address Fax Number:
503-861-2043
Provider Enumeration Date:
06/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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