MEDICARE: PORTLAND WELLNESS CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center	261QR0400X	OR

General Provider Information

NPI Number	:	1801286117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND WELLNESS CARE

Provider Business Mailing Address
First Line	:	1647 SE CONDOR AVE
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97080-7185
Country	:	US
Telephone Number	:	503-730-8705
Fax Number	:	503-661-7488

Provider Business Practice Location Address
First Line	:	4160 NE SANDY BLVD
Second Line	:	SUITE 1100
City	:	PORTLAND
State	:	OR
Zip	:	97212-5336
Country	:	US
Telephone Number	:	503-249-9000
Fax Number	:	503-719-6829

Authorized Official
Title or Position	:	FOUNDER
Name	:	DR. MARK E HOSKO
Credential	:	M.D.
Telephone Number	:	503-249-9000

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	04/29/2015

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Directions to “PORTLAND WELLNESS CARE ” Practice Location

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