Healthcare Provider Details

I. General information

NPI: 1730057431
Provider Name (Legal Business Name): PRIME CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 NW LINNEMAN AVE
GRESHAM OR
97030-6248
US

IV. Provider business mailing address

135 NW LINNEMAN AVE
GRESHAM OR
97030-6248
US

V. Phone/Fax

Practice location:
  • Phone: 469-688-9579
  • Fax:
Mailing address:
  • Phone: 469-688-9579
  • 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: BEZAWITE M ABEGAZ
Title or Position: DIRECTOR
Credential: RN
Phone: 469-688-9579