Basic Information
| Provider Information | |||||||||
| NPI: | 1235485053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | NICK | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064323 | ||||||||
| FaxNumber: | 5039064333 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064323 | ||||||||
| FaxNumber: | 5039064333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2012 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4066 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 4066 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 4066 | 01 | OR | OREGON LICENSE NUMBER | OTHER |