Provider Demographics
NPI:1912574906
Name:ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
Entity Type:Organization
Organization Name:ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-387-5449
Mailing Address - Street 1:2020 8TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4657
Mailing Address - Country:US
Mailing Address - Phone:503-387-5449
Mailing Address - Fax:503-342-6846
Practice Address - Street 1:11000 SW 11TH ST STE 440B
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4107
Practice Address - Country:US
Practice Address - Phone:503-387-5449
Practice Address - Fax:503-342-6846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVE EDGE PHYSICAL THERAPY & SPORTS MEDICINE P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty