Provider Demographics
NPI:1023699964
Name:PTCONNECTLLC
Entity type:Organization
Organization Name:PTCONNECTLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FAHRUELDIN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:EBED
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-473-6553
Mailing Address - Street 1:7468 EVERWOOD ST NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-7858
Mailing Address - Country:US
Mailing Address - Phone:503-451-5058
Mailing Address - Fax:
Practice Address - Street 1:7468 EVERWOOD ST NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-7858
Practice Address - Country:US
Practice Address - Phone:503-451-5058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty