Provider Demographics
NPI:1619172780
Name:PROVIDENCE SILVERTON REHAB LLC
Entity Type:Organization
Organization Name:PROVIDENCE SILVERTON REHAB LLC
Other - Org Name:WELLSPRING PHYSICAL REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-893-7295
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3290
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:1475 MT. HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9066
Practice Address - Country:US
Practice Address - Phone:971-983-5206
Practice Address - Fax:971-983-5211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE SILVERTON REHAB LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-19
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDA5512OtherRAILROAD MEDICARE PART B
ORR114945Medicare PIN