Provider Demographics
NPI:1669856571
Name:PORTLAND IOP, LLC
Entity Type:Organization
Organization Name:PORTLAND IOP, LLC
Other - Org Name:KLEAN GRESHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALIXAUNDREA
Authorized Official - Middle Name:CORRIN
Authorized Official - Last Name:POLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-969-4787
Mailing Address - Street 1:2675 NW THURMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2202
Mailing Address - Country:US
Mailing Address - Phone:503-825-7046
Mailing Address - Fax:503-432-8913
Practice Address - Street 1:748 SE 181ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4945
Practice Address - Country:US
Practice Address - Phone:503-825-7046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder