Provider Demographics
NPI:1053326561
Name:PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF EAST VANCOUVER LLC
Entity Type:Organization
Organization Name:PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF EAST VANCOUVER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-740-8847
Mailing Address - Street 1:PO BOX 52194
Mailing Address - Street 2:DEPT CODE 964
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:503-489-1781
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:6700 NE 162ND AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-3858
Practice Address - Country:US
Practice Address - Phone:360-567-0633
Practice Address - Fax:360-567-0635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7136179Medicaid
WA7136179Medicaid