Provider Demographics
NPI:1578818951
Name:PEDAL PT, LLC
Entity Type:Organization
Organization Name:PEDAL PT, LLC
Other - Org Name:PEDAL PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CMP
Authorized Official - Phone:503-453-4993
Mailing Address - Street 1:2719 SE 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1201
Mailing Address - Country:US
Mailing Address - Phone:503-453-4993
Mailing Address - Fax:
Practice Address - Street 1:2622 SE 25TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1217
Practice Address - Country:US
Practice Address - Phone:503-453-4993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4465261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1811039035Medicare PIN