Provider Demographics
NPI:1154647329
Name:PROACTIVE PHYSICAL THERAPY -SALMON CREEK
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY -SALMON CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-740-8847
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:
Mailing Address - Fax:
Practice Address - Street 1:2621 NE 134TH ST
Practice Address - Street 2:SUITE 310
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3036
Practice Address - Country:US
Practice Address - Phone:503-489-1174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy