Healthcare Provider Details

I. General information

NPI: 1760123764
Provider Name (Legal Business Name): KINETIX PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3871 FAIRVIEW INDUSTRIAL DR SE STE 120
SALEM OR
97302-1172
US

IV. Provider business mailing address

3871 FAIRVIEW INDUSTRIAL DR SE STE 120
SALEM OR
97302-1172
US

V. Phone/Fax

Practice location:
  • Phone: 503-990-6393
  • Fax: 503-794-0103
Mailing address:
  • Phone: 503-990-6393
  • Fax: 503-794-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOMONIQUE RUSCITTI
Title or Position: BILLING & CONTRACTING SPECIALIST
Credential:
Phone: 971-274-2861