Provider Demographics
NPI:1790118495
Name:VANTINE, ALBERT FREDERICK (PTA)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:FREDERICK
Last Name:VANTINE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 SUNMIST CT SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1201
Mailing Address - Country:US
Mailing Address - Phone:541-961-0137
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER ST STE 203
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:888-317-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8864225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant