Healthcare Provider Details

I. General information

NPI: 1558487116
Provider Name (Legal Business Name): MICHAEL OXENTENKO II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 SE POWELL VALLEY RD
GRESHAM OR
97080-1919
US

IV. Provider business mailing address

43131 SE MUSIC CAMP RD
SANDY OR
97055-8463
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-1151
  • Fax: 503-669-1986
Mailing address:
  • Phone: 503-665-1151
  • Fax: 503-669-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1040
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: