Healthcare Provider Details

I. General information

NPI: 1467413179
Provider Name (Legal Business Name): PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 SE STARK ST SUITE 103
GRESHAM OR
97030-3331
US

IV. Provider business mailing address

PO BOX 52194 DEPT CODE 961
PHOENIX AZ
85072-2194
US

V. Phone/Fax

Practice location:
  • Phone: 503-328-0222
  • Fax: 503-328-0223
Mailing address:
  • Phone: 503-489-1781
  • Fax: 503-489-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number20573
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. LARRY DEAN KROUT
Title or Position: MANAGING MEMBER
Credential:
Phone: 503-740-8847