Healthcare Provider Details

I. General information

NPI: 1114850245
Provider Name (Legal Business Name): KANEWOOD RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SE KANE DR
GRESHAM OR
97080-1628
US

IV. Provider business mailing address

425 SE KANE DR
GRESHAM OR
97080-1628
US

V. Phone/Fax

Practice location:
  • Phone: 503-927-9202
  • Fax: 503-927-9202
Mailing address:
  • Phone: 503-927-9202
  • Fax: 503-927-9202

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: MR. ALAZAR KASSA
Title or Position: ADMINISTRATOR
Credential:
Phone: 503-927-9202