Healthcare Provider Details

I. General information

NPI: 1861092520
Provider Name (Legal Business Name): W2 POWELL VALLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 SE 182ND AVE
GRESHAM OR
97030-5063
US

IV. Provider business mailing address

4001 SE 182ND AVE
GRESHAM OR
97030-5063
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-2496
  • Fax:
Mailing address:
  • Phone: 503-665-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: TREVOR WART
Title or Position: MANAGER
Credential:
Phone: 503-706-6918