| Gateway To Rejuvenation | |
|
1312 E Burnside St Portland OR 97214-1424 | |
| (503) 205-1669 | |
| Not Available |
| Full Name | Gateway To Rejuvenation |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 1312 E Burnside St, Portland, Oregon |
| Authorized Official Name and Position | Omolola A Elliott (THERAPIST) |
| Authorized Official Contact | 9712123146 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Gateway To Rejuvenation 3439 Ne Sandy Blvd Ste 216 Portland OR 97232-1959 Ph: (503) 205-1669 | Gateway To Rejuvenation 1312 E Burnside St Portland OR 97214-1424 Ph: (503) 205-1669 |
| NPI Number | 1407388812 |
|---|---|
| Provider Enumeration Date | 04/03/2017 |
| Last Update Date | 04/03/2017 |
| Medicare PECOS PAC ID | 8325473788 |
|---|---|
| Medicare Enrollment ID | O20231009001828 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407388812 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | L7113 (Oregon) | Primary |
| Provider Name | Omolola Adeyemi Elliott |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1285174680 PECOS PAC ID: 7416291166 Enrollment ID: I20231009001980 |
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