Basic Information
| Provider Information | |||||||||
| NPI: | 1790760908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE REHABILITATION ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 SW MARLOW AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032920765 | ||||||||
| FaxNumber: | 5032925208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 SW MARLOW AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032920765 | ||||||||
| FaxNumber: | 5032925208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5032920765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.