Basic Information
| Provider Information | |||||||||
| NPI: | 1730718768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 SW 196TH AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970784343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035028586 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15700 SW GREYSTONE CT | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970066011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | 5011 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No ID Information.