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General NPI Number Information
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NPI Number | 1790593739
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Entity Type | Organization
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Legal Business Name | STOUT PERFORMANCE AND PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 12/23/2024
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Last Update Date | 12/23/2024
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Provider Practice Location Address
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Address Line | 710 NE HOLLADAY ST # 150
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City | PORTLAND
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State | OR
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Zip | 97232-2168
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Country | US
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Telephone | 503-542-2744
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Fax |
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Provider Business Mailing Address
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Address Line | 710 NE HOLLADAY ST # 150
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City | PORTLAND
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State | OR
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Zip | 97232-2168
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | JAKE STOUT
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Credential |
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Telephone | 503-949-1727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number |
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License Number State |
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