Healthcare Provider Details

I. General information

NPI: 1659282853
Provider Name (Legal Business Name): 205 YACOB RTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 SE TAYLOR ST
PORTLAND OR
97216-2126
US

IV. Provider business mailing address

9350 SE TAYLOR ST
PORTLAND OR
97216-2126
US

V. Phone/Fax

Practice location:
  • Phone: 503-830-7800
  • Fax:
Mailing address:
  • Phone: 503-296-2905
  • 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: AGERNESH N BOGALE
Title or Position: OWNER
Credential:
Phone: 503-830-7800