Healthcare Provider Details

I. General information

NPI: 1750521985
Provider Name (Legal Business Name): 111TH SQUARE FITNESS AND THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 NE HALSEY ST
PORTLAND OR
97220-2021
US

IV. Provider business mailing address

11126 NE HALSEY ST
PORTLAND OR
97220-2021
US

V. Phone/Fax

Practice location:
  • Phone: 503-256-5200
  • Fax: 503-253-7958
Mailing address:
  • Phone: 503-256-5200
  • Fax: 503-253-7958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15397
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1333261
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0355
License Number StateOR

VIII. Authorized Official

Name: MS. LINDA JOSEPHINE SANCHEZ
Title or Position: MAKER
Credential:
Phone: 503-256-5200