Healthcare Provider Details

I. General information

NPI: 1720934482
Provider Name (Legal Business Name): PACIFIC WELLNESS PATHWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 NE 18TH CT
GRESHAM OR
97030-4328
US

IV. Provider business mailing address

3085 NE 18TH CT
GRESHAM OR
97030-4328
US

V. Phone/Fax

Practice location:
  • Phone: 813-385-8389
  • Fax:
Mailing address:
  • Phone: 813-385-8389
  • 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: SAMIRAWIT ADUGNA BIRATU
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 813-385-8389