Provider Demographics
NPI:1760839815
Name:ROGER MILLER LAKE OSWEGO PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ROGER MILLER LAKE OSWEGO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:COMP FAAOMPT
Authorized Official - Phone:971-204-0600
Mailing Address - Street 1:6464 SW BORLAND RD STE B5
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8859
Mailing Address - Country:US
Mailing Address - Phone:971-204-0600
Mailing Address - Fax:971-204-0602
Practice Address - Street 1:15110 BOONES FERRY RD STE 230
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3497
Practice Address - Country:US
Practice Address - Phone:971-204-0600
Practice Address - Fax:971-204-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPT0851261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy