Provider Demographics
NPI:1235111360
Name:COSTAIN, RICHARD SCOTT (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:COSTAIN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:631 ELM ST SW
Practice Address - Street 2:STE 205
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1952
Practice Address - Country:US
Practice Address - Phone:541-967-1224
Practice Address - Fax:541-967-2750
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR280560Medicaid
OR00WCXBQAMedicare PIN