Healthcare Provider Details

I. General information

NPI: 1164327052
Provider Name (Legal Business Name): HEARTLAND RTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 NE 194TH CT
PORTLAND OR
97230-7725
US

IV. Provider business mailing address

911 SE 187TH AVE APT 203
PORTLAND OR
97233-5459
US

V. Phone/Fax

Practice location:
  • Phone: 971-331-1781
  • Fax:
Mailing address:
  • Phone: 971-331-1781
  • 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 StateNULL

VIII. Authorized Official

Name: TEWODROS ESTIFANOS AYELE
Title or Position: MANAGER
Credential:
Phone: 971-331-1781