Provider Demographics
NPI:1003295775
Name:PROACTIVE PHYSICAL THERAPY TUALATIN
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY TUALATIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR / CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-489-6250
Mailing Address - Street 1:1480 NE VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3827
Mailing Address - Country:US
Mailing Address - Phone:503-489-6250
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-545-0526
Practice Address - Fax:503-855-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty