=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073479804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENEMIND RTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2025
-----------------------------------------------------
Last Update Date | 12/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 688 SE 37TH AVE
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-7427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-422-8583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 688 SE 37TH AVE
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-7427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-422-8583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | GRUME A MEKONNEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-422-8583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------