=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265315709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWER UP COMMUNITY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2025
-----------------------------------------------------
Last Update Date | 03/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 SW 5TH AVE STE 3150
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-230-9970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 SW 5TH AVE STE 3150
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-901-4411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANTONIO JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-901-4411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------