Basic Information
| Provider Information | |||||||||
| NPI: | 1467413179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52194 | ||||||||
| Address2: | DEPT CODE 961 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850722194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891781 | ||||||||
| FaxNumber: | 5034891650 | ||||||||
| Practice Location | |||||||||
| Address1: | 25500 SE STARK ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033280222 | ||||||||
| FaxNumber: | 5033280223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | KROUT | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5037408847 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 20573 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.