Basic Information
| Provider Information | |||||||||
| NPI: | 1346228731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOHLEY | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4236022028 | ||||||||
| Practice Location | |||||||||
| Address1: | 38505 BROOTEN RD STE C | ||||||||
| Address2: | |||||||||
| City: | PACIFIC CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039656400 | ||||||||
| FaxNumber: | 5039659555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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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 | 4204 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 182881 | 05 | OR | MEDICAID |