Healthcare Provider Details

I. General information

NPI: 1043292311
Provider Name (Legal Business Name): CLEM GEORGE EISCHEN JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST
GRESHAM OR
97030-3162
US

IV. Provider business mailing address

31541 SE DIVISION DR
TROUTDALE OR
97060-8422
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-1666
  • Fax:
Mailing address:
  • Phone: 503-663-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1517
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: