Organization
PORTLAND DETOX
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRAD WHISNANT LAC (OWNER)
(503) 750-6238
Entity
Organization
Contact information
Practice address
11160 SW WAVERLY PL, PORTLAND, OR 97225-4456
(503) 750-6238
Mailing address
11160 SW WAVERLY PL, PORTLAND, OR 97225-4456
(503) 750-6238
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
AC01151
OR
Other
Enumeration date
03/24/2009
Last updated
03/24/2009
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