1962766212 NPI number — PORTLAND PRO HEALTH THERAPIES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962766212 NPI number — PORTLAND PRO HEALTH THERAPIES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND PRO HEALTH THERAPIES, PC
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:
Provider Other Organization Name Type Code:
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:
1962766212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5806 NE HALSEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97213-3670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-262-1006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8730 SW TERWILLIGER BLVD
Provider Second Line Business Practice Location Address:
SUITE 202B
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-4586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-298-5744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-262-1006

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3614 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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