Healthcare Provider Details

I. General information

NPI: 1235111360
Provider Name (Legal Business Name): RICHARD SCOTT COSTAIN PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 ELM ST SW STE 205
ALBANY OR
97321-1952
US

IV. Provider business mailing address

11481 SW HALL BLVD STE 201
PORTLAND OR
97223-8403
US

V. Phone/Fax

Practice location:
  • Phone: 541-967-1224
  • Fax: 541-967-2750
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1048
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: