Provider Demographics
NPI:1669887691
Name:ACTIVE RECOVERY AND MANUAL PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:ACTIVE RECOVERY AND MANUAL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PTA
Authorized Official - Prefix:
Authorized Official - First Name:PAULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISEL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, PTA
Authorized Official - Phone:541-337-0171
Mailing Address - Street 1:12014 SE SCHILLER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12014 SE SCHILLER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-3258
Practice Address - Country:US
Practice Address - Phone:541-337-0171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-28
Last Update Date:2014-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy