1912574906 NPI number — ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.

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 1912574906 NPI number — ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
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:
1912574906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 8TH AVE STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LINN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97068-4657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-387-5449
Provider Business Mailing Address Fax Number:
503-342-6846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11000 SW 11TH ST STE 440B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97005-4107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-387-5449
Provider Business Practice Location Address Fax Number:
503-342-6846
Provider Enumeration Date:
06/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MORLAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-387-5449

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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