Provider Demographics
NPI:1760443477
Name:PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF OREGON CITY LLC
Entity Type:Organization
Organization Name:PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF OREGON CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-740-8847
Mailing Address - Street 1:PO BOX 52194
Mailing Address - Street 2:DEPT CODE 962
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:503-489-1781
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:1001 MOLALLA AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-607-0047
Practice Address - Fax:503-607-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4484261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000131Medicaid
OR000131Medicaid
ORR114556Medicare PIN
ORR134327Medicare PIN