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General NPI Number Information
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NPI Number | 1750521985
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Entity Type | Organization
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Legal Business Name | 111TH SQUARE FITNESS AND THERAPY, LLC
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Dates
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Enumeration Date | 02/27/2009
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Last Update Date | 02/27/2009
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Provider Practice Location Address
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Address Line | 11126 NE HALSEY ST
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City | PORTLAND
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State | OR
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Zip | 97220-2021
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Country | US
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Telephone | 503-256-5200
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Fax | 503-253-7958
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Provider Business Mailing Address
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Address Line | 11126 NE HALSEY ST
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City | PORTLAND
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State | OR
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Zip | 97220-2021
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Country | US
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Telephone | 503-256-5200
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Fax | 503-253-7958
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Authorized Official
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Title or Position | MAKER
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Name | MS. LINDA JOSEPHINE SANCHEZ
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Credential |
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Telephone | 503-256-5200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 15397
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1333261
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 0355
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License Number State | OR
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