Provider Demographics
NPI:1497872022
Name:TRAILS END PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:TRAILS END PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:503-655-6777
Mailing Address - Street 1:1506 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1450
Mailing Address - Country:US
Mailing Address - Phone:503-655-6777
Mailing Address - Fax:503-655-6778
Practice Address - Street 1:1506 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1450
Practice Address - Country:US
Practice Address - Phone:503-655-6777
Practice Address - Fax:503-655-6778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1851225100000X
OR10635225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298959Medicaid
ORR133640Medicare PIN