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General NPI Number Information
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NPI Number | 1801115183
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF YOUTH PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 05/25/2010
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Last Update Date | 05/25/2010
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Provider Practice Location Address
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Address Line | 9860 SW HALL BLVD STE A3
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City | TIGARD
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State | OR
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Zip | 97223-8896
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Country | US
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Telephone | 503-902-2123
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Fax |
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Provider Business Mailing Address
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Address Line | 664 SW RUSTICA TER
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City | PORTLAND
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State | OR
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Zip | 97225-7057
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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 | PHYSICAL THERAPIST
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Name | LAURA L WALICZEK
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Credential | PT, DPT
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Telephone | 503-327-4195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4954
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License Number State | OR
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