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30 Ne Martin Luther King Blvd Portland OR 97232-2941 | |
| (503) 232-1099 | |
| (503) 232-3854 |
| Full Name | |
|---|---|
| Speciality | Community Based Residential Treatment Facility, Mental Illness |
| Location | 30 Ne Martin Luther King Blvd, Portland, Oregon |
| Authorized Official Name and Position | Leslie Davis (SVP, CFO) |
| Authorized Official Contact | 5103377950 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1080 Marina Village Pkwy Suite 100 Alameda CA 94501-6427 Ph: (510) 337-7950 | 30 Ne Martin Luther King Blvd Portland OR 97232-2941 Ph: (503) 232-1099 |
| NPI Number | 1124310305 |
|---|---|
| Provider Enumeration Date | 05/06/2011 |
| Last Update Date | 01/11/2022 |
| Certification Date | 01/11/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124310305 | NPI | - | NPPES |
| 500635141 | Medicaid | OR |
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