Provider Demographics
NPI:1750420063
Name:PETTYGROVE PHYSICAL THERPAY ASSOCIATES LLC
Entity type:Organization
Organization Name:PETTYGROVE PHYSICAL THERPAY ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-228-1306
Mailing Address - Street 1:1515 NW 18TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97123
Mailing Address - Country:US
Mailing Address - Phone:503-228-1306
Mailing Address - Fax:503-228-1307
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-228-1306
Practice Address - Fax:503-228-1307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR102810Medicare ID - Type Unspecified