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General NPI Number Information
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NPI Number | 1982313995
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Entity Type | Organization
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Legal Business Name | LEADING EDGE PHYSICAL THERAPY
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Dates
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Enumeration Date | 11/17/2022
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Last Update Date | 10/06/2023
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Provider Practice Location Address
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Address Line | 1100 LIBERTY ST SE STE 100
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City | SALEM
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State | OR
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Zip | 97302-5385
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Country | US
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Telephone | 503-500-5727
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Fax | 971-273-2706
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Provider Business Mailing Address
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Address Line | 5477 BELLFLOWER ST SE
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City | SALEM
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State | OR
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Zip | 97306-1648
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Country | US
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Telephone | 503-500-5727
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW HENNINGS
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Credential | DPT
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Telephone | 503-500-5727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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