MEDICARE: NW INSITUTO LATINO

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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1114546645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NW INSITUTO LATINO

Provider Business Mailing Address
First Line	:	775 NE 9TH ST
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97030-5668
Country	:	US
Telephone Number	:	503-888-3464
Fax Number	:

Provider Business Practice Location Address
First Line	:	2054 N VANCOUVER AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1917
Country	:	US
Telephone Number	:	503-888-3464
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MIGUEL TELLEZ
Credential	:
Telephone Number	:	503-888-3464

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	04/14/2020

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Directions to “NW INSITUTO LATINO ” Practice Location

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