Provider Demographics
NPI:1235778333
Name:WESTON SPORTS PERFORMANCE REHABILITATION LLC
Entity Type:Organization
Organization Name:WESTON SPORTS PERFORMANCE REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LOCKE
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-335-2543
Mailing Address - Street 1:777 NW 19TH AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1391
Mailing Address - Country:US
Mailing Address - Phone:860-335-2543
Mailing Address - Fax:
Practice Address - Street 1:777 NW 19TH AVE APT 107
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1391
Practice Address - Country:US
Practice Address - Phone:860-335-2543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty