Healthcare Provider Details

I. General information

NPI: 1790593739
Provider Name (Legal Business Name): STOUT PERFORMANCE AND PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 NE HOLLADAY ST # 150
PORTLAND OR
97232-2168
US

IV. Provider business mailing address

710 NE HOLLADAY ST # 150
PORTLAND OR
97232-2168
US

V. Phone/Fax

Practice location:
  • Phone: 503-542-2744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JAKE STOUT
Title or Position: OWNER/PROVIDER
Credential:
Phone: 503-949-1727