Healthcare Provider Details

I. General information

NPI: 1659284206
Provider Name (Legal Business Name): PACIFICNEST RTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20373 SW BLAINE CT
BEAVERTON OR
97003-2115
US

IV. Provider business mailing address

20373 SW BLAINE CT
BEAVERTON OR
97003-2115
US

V. Phone/Fax

Practice location:
  • Phone: 515-512-6210
  • Fax:
Mailing address:
  • Phone:
  • 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: YOHANNESE B LEGESSE
Title or Position: OWNER
Credential:
Phone: 515-512-6210