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General NPI Number Information
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NPI Number | 1215127873
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Entity Type | Organization
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Legal Business Name | PORTLAND SPORTS MEDICINE & SPINE PHYSICAL THERAPY INC.
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Dates
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Enumeration Date | 07/30/2007
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Last Update Date | 07/30/2007
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Provider Practice Location Address
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Address Line | 1610 SE GLENWOOD ST
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City | PORTLAND
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State | OR
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Zip | 97202-5615
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Country | US
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Telephone | 503-230-1744
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Fax | 503-230-1745
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Provider Business Mailing Address
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Address Line | 1610 SE GLENWOOD ST
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City | PORTLAND
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State | OR
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Zip | 97202-5615
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Country | US
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Telephone | 503-230-1744
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Fax | 503-230-1745
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MR. MICHAEL PAUL QUESNELL
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Credential | P.T.
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Telephone | 503-230-1744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 4503
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License Number State | OR
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