Provider Demographics
NPI:1801286117
Name:PORTLAND WELLNESS CARE
Entity type:Organization
Organization Name:PORTLAND WELLNESS CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOSKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-249-9000
Mailing Address - Street 1:1647 SE CONDOR AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7185
Mailing Address - Country:US
Mailing Address - Phone:503-730-8705
Mailing Address - Fax:503-661-7488
Practice Address - Street 1:4160 NE SANDY BLVD
Practice Address - Street 2:SUITE 1100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5336
Practice Address - Country:US
Practice Address - Phone:503-249-9000
Practice Address - Fax:503-719-6829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QR0400X261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation