Provider Demographics
NPI:1003135658
Name:NEW LEAF PHYSICAL AND MASSAGE THERAPY, LLC
Entity Type:Organization
Organization Name:NEW LEAF PHYSICAL AND MASSAGE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAMLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-318-0654
Mailing Address - Street 1:2734 SE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1547
Mailing Address - Country:US
Mailing Address - Phone:503-657-8663
Mailing Address - Fax:503-723-3180
Practice Address - Street 1:4050 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1828
Practice Address - Country:US
Practice Address - Phone:503-318-0654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty