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4805 Ne Glisan St Suite 6n50 Portland OR 97213-2933 | |
| (503) 216-1150 | |
| (503) 216-1066 |
| Full Name | |
|---|---|
| Speciality | Clinic/center |
| Location | 4805 Ne Glisan St, Portland, Oregon |
| Authorized Official Name and Position | Keenan B Freeman (CFO) |
| Authorized Official Contact | 5035936524 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 3158 Portland OR 97208-3158 Ph: () - | 4805 Ne Glisan St Suite 6n50 Portland OR 97213-2933 Ph: (503) 216-1150 |
| NPI Number | 1336311554 |
|---|---|
| Provider Enumeration Date | 03/27/2008 |
| Last Update Date | 09/10/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336311554 | NPI | - | NPPES |
| 279129 | Medicaid | OR |
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