Provider Demographics
NPI:1003183302
Name:NORTH LAKE PHYSICAL THERAPY AND REHABILITATION, INC.
Entity Type:Organization
Organization Name:NORTH LAKE PHYSICAL THERAPY AND REHABILITATION, INC.
Other - Org Name:KOSTA, CHOATE AND PIERSON, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT, NORTH LAKE PHYSICAL THER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOATE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:503-636-3028
Mailing Address - Street 1:101 S STATE ST STE 200G
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3900
Mailing Address - Country:US
Mailing Address - Phone:503-636-3028
Mailing Address - Fax:503-636-1837
Practice Address - Street 1:4606 SE BOARDMAN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-5930
Practice Address - Country:US
Practice Address - Phone:503-353-9776
Practice Address - Fax:503-353-9777
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH LAKE PHYSICAL THERAPY AND REHABILITATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBRKMedicare PIN