Provider Demographics
NPI:1134363708
Name:MIRANDA PHYSICAL THERAPY P.C.
Entity type:Organization
Organization Name:MIRANDA PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:C
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:503-496-1058
Mailing Address - Street 1:10151 SE SUNNYSIDE RD STE 310
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6913
Mailing Address - Country:US
Mailing Address - Phone:503-496-1058
Mailing Address - Fax:888-675-5282
Practice Address - Street 1:10151 SE SUNNYSIDE RD STE 310
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6913
Practice Address - Country:US
Practice Address - Phone:503-496-1058
Practice Address - Fax:888-675-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty