Provider Demographics
NPI:1790760908
Name:PROGRESSIVE REHABILITATION ASSOCIATES LLC
Entity Type:Organization
Organization Name:PROGRESSIVE REHABILITATION ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONAL CRED MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-272-3463
Mailing Address - Street 1:1815 SW MARLOW AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5185
Mailing Address - Country:US
Mailing Address - Phone:503-292-0765
Mailing Address - Fax:503-292-5208
Practice Address - Street 1:1815 SW MARLOW AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-292-0765
Practice Address - Fax:503-292-5208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
111753Medicare ID - Type Unspecified