Provider Demographics
NPI:1710403340
Name:DNA PHYSICAL THERAPY AND ATHLETIC CLUB, LLC
Entity Type:Organization
Organization Name:DNA PHYSICAL THERAPY AND ATHLETIC CLUB, LLC
Other - Org Name:DNA PHYSICAL THERAPY & ATHLETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:BULAT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-308-2814
Mailing Address - Street 1:128 NICHOLAS WAY
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2354
Mailing Address - Country:US
Mailing Address - Phone:503-423-7456
Mailing Address - Fax:
Practice Address - Street 1:12305 SW HORIZON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9500
Practice Address - Country:US
Practice Address - Phone:971-708-6113
Practice Address - Fax:971-708-6988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty