Healthcare Provider Details

I. General information

NPI: 1093674103
Provider Name (Legal Business Name): WALTER MAKWORO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 NE 20TH DR
GRESHAM OR
97030-2807
US

IV. Provider business mailing address

425 NE 20TH DR
GRESHAM OR
97030-2807
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-5132
  • Fax:
Mailing address:
  • Phone: 503-489-5132
  • 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 StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: