Healthcare Provider Details

I. General information

NPI: 1467771121
Provider Name (Legal Business Name): TRG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 SW BARNES RD
PORTLAND OR
97225-6603
US

IV. Provider business mailing address

PO BOX 25180
PORTLAND OR
97298-0180
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-4830
  • Fax:
Mailing address:
  • Phone: 503-292-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: HOLLY WALLNER
Title or Position: MANAGER
Credential:
Phone: 503-797-6356