Provider Demographics
NPI:1982313995
Name:LEADING EDGE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LEADING EDGE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-500-5727
Mailing Address - Street 1:5477 BELLFLOWER ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1648
Mailing Address - Country:US
Mailing Address - Phone:503-500-5727
Mailing Address - Fax:
Practice Address - Street 1:1100 LIBERTY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5385
Practice Address - Country:US
Practice Address - Phone:503-500-5727
Practice Address - Fax:971-273-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy