Provider Demographics
NPI:1881077204
Name:FUNCTION THERAPEUTICS LLC
Entity type:Organization
Organization Name:FUNCTION THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:INGRID
Authorized Official - Last Name:KIBGIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:503-922-9895
Mailing Address - Street 1:PO BOX 86745
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97286
Mailing Address - Country:US
Mailing Address - Phone:503-922-9895
Mailing Address - Fax:
Practice Address - Street 1:7925 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2341
Practice Address - Country:US
Practice Address - Phone:503-922-9895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1069622261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation