Provider Demographics
NPI:1982748141
Name:GATEWAY PARKROSE SPORTS CARE PT LLC
Entity Type:Organization
Organization Name:GATEWAY PARKROSE SPORTS CARE PT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRICKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-257-9881
Mailing Address - Street 1:10748 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3961
Mailing Address - Country:US
Mailing Address - Phone:502-257-9881
Mailing Address - Fax:503-257-8964
Practice Address - Street 1:10748 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:502-257-9881
Practice Address - Fax:503-257-8964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1660261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104781Medicare ID - Type Unspecified