Provider Demographics
NPI:1457491169
Name:NW SPINE MANAGEMENT REHABILITATION AND SPORTS CONDITIONING, INC
Entity Type:Organization
Organization Name:NW SPINE MANAGEMENT REHABILITATION AND SPORTS CONDITIONING, INC
Other - Org Name:SPORTS INJURY MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNEDRIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BECKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-227-8087
Mailing Address - Street 1:9755 SW BARNES RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6651
Mailing Address - Country:US
Mailing Address - Phone:503-227-8087
Mailing Address - Fax:503-227-8175
Practice Address - Street 1:9755 SW BARNES RD
Practice Address - Street 2:SUITE 510
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6651
Practice Address - Country:US
Practice Address - Phone:503-227-8087
Practice Address - Fax:503-227-8175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty