1760443477 NPI number — PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF OREGON CITY LLC

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 1760443477 NPI number — PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF OREGON CITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF OREGON CITY 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:
1760443477
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 962
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:
1001 MOLALLA AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-607-0047
Provider Business Practice Location Address Fax Number:
503-607-0051
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRAUT
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:  4484 , 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)

  • Identifier: 000131 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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