Provider Demographics
NPI:1649412511
Name:PORTLAND DETOX
Entity Type:Organization
Organization Name:PORTLAND DETOX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WHISNANT
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-750-6238
Mailing Address - Street 1:11160 SW WAVERLY PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4456
Mailing Address - Country:US
Mailing Address - Phone:503-750-6238
Mailing Address - Fax:
Practice Address - Street 1:11160 SW WAVERLY PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-4456
Practice Address - Country:US
Practice Address - Phone:503-750-6238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01151324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility