Organization
DUST AVENGERS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MACKENZIE RYAN (SOLE MEMBER)
(503) 479-8376
Entity
Organization
Contact information
Practice address
820 NW 12TH AVE APT 308, PORTLAND, OR 97209-3046
(503) 479-8376
Mailing address
820 NW 12TH AVE APT 308, PORTLAND, OR 97209-3046
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
251V00000X
Voluntary or Charitable Agency
—
—
253Z00000X
In Home Supportive Care Agency
Primary
—
—
261QC1800X
Corporate Health Clinic/Center
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
Other
Enumeration date
12/09/2024
Last updated
12/09/2024
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