Healthcare Provider Details

I. General information

NPI: 1992466817
Provider Name (Legal Business Name): TRACING BETA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 15TH PL
FOREST GROVE OR
97116-3107
US

IV. Provider business mailing address

2801 15TH PL
FOREST GROVE OR
97116-3107
US

V. Phone/Fax

Practice location:
  • Phone: 352-219-5930
  • Fax:
Mailing address:
  • Phone: 352-219-5930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON BOUWKAMP
Title or Position: PHYSICAL THERAPIST AND OWNER
Credential: PT, DPT, MS, CSCS
Phone: 352-219-5930