Provider Demographics
NPI:1508005026
Name:CUSTOM CARE PHYSICAL THERAPY, LLC.
Entity Type:Organization
Organization Name:CUSTOM CARE PHYSICAL THERAPY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-357-1706
Mailing Address - Street 1:3838 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2224
Mailing Address - Country:US
Mailing Address - Phone:503-357-1706
Mailing Address - Fax:503-270-5023
Practice Address - Street 1:3838 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2224
Practice Address - Country:US
Practice Address - Phone:503-357-1706
Practice Address - Fax:503-270-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3440261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136956Medicaid
OR136956Medicare PIN
R145480Medicare UPIN