Provider Demographics
NPI:1831312818
Name:ADVANCE SPORTS & SPINE THERAPY LLC
Entity Type:Organization
Organization Name:ADVANCE SPORTS & SPINE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:MARCEL
Authorized Official - Last Name:TENOSO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-723-0347
Mailing Address - Street 1:1554 GARDEN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3278
Mailing Address - Country:US
Mailing Address - Phone:503-723-0347
Mailing Address - Fax:503-655-9305
Practice Address - Street 1:1554 GARDEN ST # 103
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3278
Practice Address - Country:US
Practice Address - Phone:503-723-0347
Practice Address - Fax:503-655-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112514Medicare PIN
ORR112514Medicare UPIN