MEDICARE: ORTC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QM2800X	Methadone Clinic

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003762196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTC, LLC

Provider Business Mailing Address
First Line	:	2121 ISAACS AVE
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-2215
Country	:	US
Telephone Number	:	253-263-7057
Fax Number	:	541-237-0988

Provider Business Practice Location Address
First Line	:	2121 ISAACS AVE
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-2215
Country	:	US
Telephone Number	:	509-578-1492
Fax Number	:	509-578-1493

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	DANA JORGENSEN
Credential	:
Telephone Number	:	541-322-1794

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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