Basic Information
| Provider Information | |||||||||
| NPI: | 1134584774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE EDGE PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2090 TANNER CREEK LN | ||||||||
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| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033875449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19721 S HIGHWAY 213 | ||||||||
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| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033875449 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2015 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORLAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5033875449 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 04568 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.