Provider Demographics
NPI:1922139534
Name:PORTLAND AVENUE CLINIC MANAGEMENT
Entity Type:Organization
Organization Name:PORTLAND AVENUE CLINIC MANAGEMENT
Other - Org Name:PORTLAND AVENUE FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:POLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-476-9121
Mailing Address - Street 1:4314 E PORTLAND AVE
Mailing Address - Street 2:SUITE7
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-4696
Mailing Address - Country:US
Mailing Address - Phone:253-476-9121
Mailing Address - Fax:253-476-8942
Practice Address - Street 1:4314 E PORTLAND AVE
Practice Address - Street 2:SUITE7
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4696
Practice Address - Country:US
Practice Address - Phone:253-476-9121
Practice Address - Fax:253-476-8942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084163Medicaid
WAGAB24363Medicare ID - Type Unspecified