Provider Demographics
NPI:1841226263
Name:WESTSIDE SPINE & SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WESTSIDE SPINE & SPORTS PHYSICAL THERAPY
Other - Org Name:WESTSIDE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-466-9800
Mailing Address - Street 1:16265 NW CORNELL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4868
Mailing Address - Country:US
Mailing Address - Phone:503-466-9800
Mailing Address - Fax:503-466-9817
Practice Address - Street 1:16265 NW CORNELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4868
Practice Address - Country:US
Practice Address - Phone:503-466-9800
Practice Address - Fax:503-466-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19746261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117251Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER