MEDICARE: 360 DEGREE SPORTS MEDICINE & SPINE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	3018	OR
2	2251X0800X	Orthopedic Physical Therapist

General Provider Information

NPI Number	:	1528268588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	360 DEGREE SPORTS MEDICINE & SPINE THERAPY LLC

Provider Business Mailing Address
First Line	:	1215 SE 8TH AVE.
Second Line	:	SUITE D
City	:	PORTLAND
State	:	OR
Zip	:	97214
Country	:	US
Telephone Number	:	503-248-0360
Fax Number	:	503-334-3675

Provider Business Practice Location Address
First Line	:	1215 SE 8TH AVE.
Second Line	:	SUITE D
City	:	PORTLAND
State	:	OR
Zip	:	97214
Country	:	US
Telephone Number	:	503-248-0360
Fax Number	:	503-334-3675

Authorized Official
Title or Position	:	CEO
Name	:	MICHELLE COFFMAN
Credential	:	P.T.
Telephone Number	:	503-248-0360

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	10/31/2022

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