=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902440126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE VINTAGE PHYSICAL THERAPY AND TRAINING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2019
-----------------------------------------------------
Last Update Date | 11/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 WILLAMETTE FALLS DR STE 100
-----------------------------------------------------
City | WEST LINN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97068-4660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-467-6046
-----------------------------------------------------
Fax | 503-296-5510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26180 SW FRENCH OAK DR
-----------------------------------------------------
City | WEST LINN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97068-9756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-467-6046
-----------------------------------------------------
Fax | 503-296-5510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MEGHAN HOOBLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-467-6046
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------