1467413179 NPI number — PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM LLC

Table of content: (NPI 1467413179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467413179 NPI number — PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM 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:
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:
1467413179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 52194
Provider Second Line Business Mailing Address:
DEPT CODE 961
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85072-2194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-489-1781
Provider Business Mailing Address Fax Number:
503-489-1650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25500 SE STARK ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-3331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-328-0222
Provider Business Practice Location Address Fax Number:
503-328-0223
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KROUT
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
503-740-8847

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  20573 , 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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