Provider Demographics
NPI:1043685068
Name:ACTIVE EDGE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ACTIVE EDGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-387-5449
Mailing Address - Street 1:2090 TANNER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3671
Mailing Address - Country:US
Mailing Address - Phone:503-387-5449
Mailing Address - Fax:503-342-6846
Practice Address - Street 1:19727 SOUTH HIGHWAY 213
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-387-5449
Practice Address - Fax:503-342-6846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR045682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty