MEDICARE: UNDONO CARE PORTLAND 1, 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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1699218925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNDONO CARE PORTLAND 1, LLC

Provider Business Mailing Address
First Line	:	2850 SE 82ND AVE UNIT 8
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-1599
Country	:	US
Telephone Number	:	503-954-3219
Fax Number	:	503-387-5223

Provider Business Practice Location Address
First Line	:	2850 SE 82ND AVE UNIT 8
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-1599
Country	:	US
Telephone Number	:	503-954-3219
Fax Number	:	503-387-5223

Authorized Official
Title or Position	:	MANAGER
Name	:	TRINH DO
Credential	:
Telephone Number	:	503-954-3219

Provider Enumeration Date	:	11/18/2016
Last Update Date	:	11/18/2016

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