Provider Demographics
NPI:1730324336
Name:ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
Entity Type:Organization
Organization Name:ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-675-0267
Mailing Address - Street 1:2020 8TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4657
Mailing Address - Country:US
Mailing Address - Phone:503-387-5449
Mailing Address - Fax:503-342-6846
Practice Address - Street 1:2020 8TH AVE STE D
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4657
Practice Address - Country:US
Practice Address - Phone:503-387-5449
Practice Address - Fax:503-342-6846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4568174400000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty