Healthcare Provider Details

I. General information

NPI: 1063332021
Provider Name (Legal Business Name): AGAPE21 RESIDENTIAL TREATMENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19755 SW BLANTON ST
BEAVERTON OR
97078-1214
US

IV. Provider business mailing address

19755 SW BLANTON ST
BEAVERTON OR
97078-1214
US

V. Phone/Fax

Practice location:
  • Phone: 702-292-3628
  • Fax:
Mailing address:
  • Phone: 702-292-3628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: YEWBLIKE MEKONNEN ZERIHUN
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 702-292-3628