Healthcare Provider Details

I. General information

NPI: 1174487813
Provider Name (Legal Business Name): DAVE 24HR RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11863 E BURNSIDE ST
PORTLAND OR
97216-3731
US

IV. Provider business mailing address

11863 E BURNSIDE ST
PORTLAND OR
97216-3731
US

V. Phone/Fax

Practice location:
  • Phone: 971-393-6460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DAWIT BERISSO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 971-393-6460