MEDICARE: INTEGRATED HEALTH CLINICS NE 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	261QM2800X	Methadone Clinic

General Provider Information

NPI Number	:	1851808562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED HEALTH CLINICS NE LLC

Provider Business Mailing Address
First Line	:	17882 SE MCLOUGHLIN BLVD
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97267-6103
Country	:	US
Telephone Number	:	503-353-9415
Fax Number	:	503-353-9409

Provider Business Practice Location Address
First Line	:	3610 NE 82ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5182
Country	:	US
Telephone Number	:	503-408-9585
Fax Number	:	503-408-9456

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	PAT EWING
Credential	:
Telephone Number	:	503-408-9585

Provider Enumeration Date	:	01/03/2018
Last Update Date	:	08/19/2020

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