Provider Demographics
NPI:1326185950
Name:BROADWAY PHYSICAL THERAPY AND SPORTS REHABILITATION, LLC
Entity Type:Organization
Organization Name:BROADWAY PHYSICAL THERAPY AND SPORTS REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-287-6636
Mailing Address - Street 1:3016 NE BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-287-6636
Mailing Address - Fax:503-287-4044
Practice Address - Street 1:3016 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1811
Practice Address - Country:US
Practice Address - Phone:503-287-6636
Practice Address - Fax:503-287-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR113610Medicare PIN