Provider Demographics
NPI:1467018739
Name:ACTIVEEDGE TUALATIN, LLP
Entity Type:Organization
Organization Name:ACTIVEEDGE TUALATIN, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-387-5449
Mailing Address - Street 1:2090 TANNER CREEK LANE
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-387-5449
Mailing Address - Fax:503-342-6846
Practice Address - Street 1:19150 SW 90TH AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-387-5449
Practice Address - Fax:503-387-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty