Provider Demographics
NPI:1013156603
Name:LIFESTYLES PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:LIFESTYLES PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:STOTT
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-235-3386
Mailing Address - Street 1:4445 SW BARBUR BLVD.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-235-3386
Mailing Address - Fax:503-239-1694
Practice Address - Street 1:4445 SW BARBUR BLVD.
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-235-3386
Practice Address - Fax:503-239-1694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1369712-7261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy