Basic Information
| Provider Information | |||||||||
| NPI: | 1467771121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25180 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9205 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032164830 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2010 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALLNER | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5037976356 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 500623355 | 05 | OR | MEDICAID |