Provider Demographics
NPI:1558495762
Name:PERFORMANCE ZONE SPORTS AND ORTHOPEDIC PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:PERFORMANCE ZONE SPORTS AND ORTHOPEDIC PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:IVINS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-371-4800
Mailing Address - Street 1:2138 LANCASTER DR NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1227
Mailing Address - Country:US
Mailing Address - Phone:503-371-4800
Mailing Address - Fax:503-371-4801
Practice Address - Street 1:2138 LANCASTER DR NE
Practice Address - Street 2:SUITE 103
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1227
Practice Address - Country:US
Practice Address - Phone:503-371-4800
Practice Address - Fax:503-371-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3584261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120139Medicare PIN