Healthcare Provider Details

I. General information

NPI: 1609635507
Provider Name (Legal Business Name): SPORTSCARE PHYSICAL THERAPY @ CORNELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST STE 210
GRESHAM OR
97030-3376
US

IV. Provider business mailing address

24076 SE STARK ST STE 210
GRESHAM OR
97030-3376
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: PENNY TACKER
Title or Position: REGULATORY SPECIALIST
Credential:
Phone: 713-297-7052