Healthcare Provider Details

I. General information

NPI: 1003679200
Provider Name (Legal Business Name): ACTIVE INJURY REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5253 NE SANDY BLVD
PORTLAND OR
97213-2562
US

IV. Provider business mailing address

1605 NE 51ST AVE
PORTLAND OR
97213-2703
US

V. Phone/Fax

Practice location:
  • Phone: 503-766-4881
  • Fax:
Mailing address:
  • Phone: 503-440-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: KEENAN BORGARDT
Title or Position: OWNER
Credential: DC
Phone: 503-440-7470