1710932710 NPI number — PROMOTION ADVANCED FUNCTIONAL REHAB LLC

Table of content: (NPI 1710932710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710932710 NPI number — PROMOTION ADVANCED FUNCTIONAL REHAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMOTION ADVANCED FUNCTIONAL REHAB LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROMOTION PHYSICAL THERAPY OF SILVERTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710932710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 N 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAYTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-769-3123
Provider Business Mailing Address Fax Number:
503-769-3176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAYTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-769-3123
Provider Business Practice Location Address Fax Number:
503-769-3123
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANGLIN
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
503-769-3123

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  4435 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , with the licence number: 2672 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 4422 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 3854 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 2662 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , with the licence number: 8535 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , with the licence number: 9133 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005957 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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