Provider Demographics
NPI:1144738790
Name:VITALITY PHYSICAL THERAPY NORTHWEST LLC
Entity Type:Organization
Organization Name:VITALITY PHYSICAL THERAPY NORTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-577-2706
Mailing Address - Street 1:7722 SE 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8537
Mailing Address - Country:US
Mailing Address - Phone:503-577-2706
Mailing Address - Fax:
Practice Address - Street 1:12755 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8373
Practice Address - Country:US
Practice Address - Phone:503-577-2706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy