Provider Demographics
NPI:1710932710
Name:PROMOTION ADVANCED FUNCTIONAL REHAB LLC
Entity Type:Organization
Organization Name:PROMOTION ADVANCED FUNCTIONAL REHAB LLC
Other - Org Name:PROMOTION PHYSICAL THERAPY OF SILVERTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-769-3123
Mailing Address - Street 1:601 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383
Mailing Address - Country:US
Mailing Address - Phone:503-769-3123
Mailing Address - Fax:503-769-3176
Practice Address - Street 1:601 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383
Practice Address - Country:US
Practice Address - Phone:503-769-3123
Practice Address - Fax:503-769-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44352251X0800X
OR26722251X0800X
OR44222251X0800X
OR38542251X0800X
OR26622251X0800X
OR8535225200000X
OR9133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005957Medicaid
ORR134555Medicare PIN