Healthcare Provider Details

I. General information

NPI: 1417934886
Provider Name (Legal Business Name): PT NORTHWEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 36TH AVE NE
SALEM OR
97301-0005
US

IV. Provider business mailing address

685 36TH AVE NE
SALEM OR
97301-4741
US

V. Phone/Fax

Practice location:
  • Phone: 503-371-8860
  • Fax: 503-371-9299
Mailing address:
  • Phone: 503-540-8701
  • Fax: 503-371-8772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNEDY I HAWKINS
Title or Position: PRESIDENT GENERAL MANAGER
Credential:
Phone: 503-540-8701