Provider Demographics
NPI:1518558469
Name:GREEN HERON PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GREEN HERON PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:URDANETA-MONCADA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:661-717-9692
Mailing Address - Street 1:PO BOX 96034
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97296-6000
Mailing Address - Country:US
Mailing Address - Phone:661-717-9692
Mailing Address - Fax:
Practice Address - Street 1:1706 NW 24TH AVE UNIT 96034
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97296-6613
Practice Address - Country:US
Practice Address - Phone:661-717-9692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy