Provider Demographics
NPI:1003679200
Name:ACTIVE INJURY REHAB, LLC
Entity Type:Organization
Organization Name:ACTIVE INJURY REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-440-7470
Mailing Address - Street 1:1605 NE 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2703
Mailing Address - Country:US
Mailing Address - Phone:503-440-7470
Mailing Address - Fax:
Practice Address - Street 1:5253 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2562
Practice Address - Country:US
Practice Address - Phone:503-766-4881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty