Provider Demographics
NPI:1821828849
Name:DE LEON, KRISTOFFER
Entity type:Individual
Prefix:
First Name:KRISTOFFER
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W ELLENDALE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1790
Mailing Address - Country:US
Mailing Address - Phone:503-623-2433
Mailing Address - Fax:
Practice Address - Street 1:210 W ELLENDALE AVE STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1790
Practice Address - Country:US
Practice Address - Phone:503-623-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist