Healthcare Provider Details

I. General information

NPI: 1063469773
Provider Name (Legal Business Name): PIVOTAL PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15899 SW BALER WAY
SHERWOOD OR
97140-8833
US

IV. Provider business mailing address

15899 SW BALER WAY
SHERWOOD OR
97140-8833
US

V. Phone/Fax

Practice location:
  • Phone: 503-625-2217
  • Fax: 503-925-1469
Mailing address:
  • Phone: 503-625-2217
  • Fax: 503-925-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4428
License Number StateOR

VIII. Authorized Official

Name: MR. JUSTIN DAVID HARLE
Title or Position: OWNER
Credential: P.T.
Phone: 503-625-2217