Provider Demographics
NPI:1184864365
Name:DIMOND PHYSICAL THERAPY AND PERFORMANCE LAB, LLC
Entity Type:Organization
Organization Name:DIMOND PHYSICAL THERAPY AND PERFORMANCE LAB, LLC
Other - Org Name:THE KOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONNEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-810-7264
Mailing Address - Street 1:735 SW 158TH AVE
Mailing Address - Street 2:STE 160
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4952
Mailing Address - Country:US
Mailing Address - Phone:503-597-0035
Mailing Address - Fax:503-296-2985
Practice Address - Street 1:735 SW 158TH AVE
Practice Address - Street 2:STE 160
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4952
Practice Address - Country:US
Practice Address - Phone:503-597-0035
Practice Address - Fax:503-296-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR520244000OtherREGENCE
OR520244000OtherREGENCE