Provider Demographics
NPI:1902440738
Name:TINA CAPUTO LMT
Entity Type:Organization
Organization Name:TINA CAPUTO LMT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAC
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPUTO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center