1003295775 NPI number — PROACTIVE PHYSICAL THERAPY TUALATIN

Table of content: (NPI 1003295775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003295775 NPI number — PROACTIVE PHYSICAL THERAPY TUALATIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE PHYSICAL THERAPY TUALATIN
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:
1003295775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1480 NE VILLAGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRVIEW
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97024-3827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-489-6250
Provider Business Mailing Address Fax Number:
503-489-1650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19255 SW 65TH AVE
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-7451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-545-0526
Provider Business Practice Location Address Fax Number:
503-855-4568
Provider Enumeration Date:
05/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCCALL
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING DIRECTOR / CREDENTIALING
Authorized Official Telephone Number:
503-489-6250

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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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