Healthcare Provider Details

I. General information

NPI: 1427225606
Provider Name (Legal Business Name): KOFOED ENTEPRISES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 SW TAYLOR STREET SUITE 665
PORTLAND OR
97205-2529
US

IV. Provider business mailing address

1020 SW TAYLOR STREET SUITE 665
PORTLAND OR
97205-2529
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-2222
  • Fax:
Mailing address:
  • Phone: 503-224-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1662
License Number StateOR

VIII. Authorized Official

Name: MS. GRETE A KOFOED
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 503-224-2222