MEDICARE: CARLY LYNN NEGRILA PT

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	225100000X	Physical Therapist	63418	OR

General Provider Information

NPI Number	:	1760031496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY LYNN NEGRILA PT

Provider Business Mailing Address
First Line	:	16083 SW UPPER BOONES FERRY RD STE 300
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97224-7736
Country	:	US
Telephone Number	:	503-443-6156
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 ELM ST STE 200
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2781
Country	:	US
Telephone Number	:	503-357-9810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2019
Last Update Date	:	09/05/2019

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Directions to “ CARLY LYNN NEGRILA PT” Practice Location

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