Provider Demographics
NPI:1407037146
Name:TUALATIN PHYSICAL THERAPY & SPORTS REHAB INC
Entity Type:Organization
Organization Name:TUALATIN PHYSICAL THERAPY & SPORTS REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASPER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-885-2199
Mailing Address - Street 1:19767 SW 72ND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8354
Mailing Address - Country:US
Mailing Address - Phone:503-885-2199
Mailing Address - Fax:503-885-2129
Practice Address - Street 1:19767 SW 72ND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8354
Practice Address - Country:US
Practice Address - Phone:503-885-2199
Practice Address - Fax:503-885-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0777225100000X
OR1583225100000X
OR1052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR107307Medicare PIN