MEDICARE: TUALATIN PHYSICAL THERAPY & SPORTS REHAB INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1583	OR
2	225100000X	Physical Therapist	1052	OR
3	225100000X	Physical Therapist	0777	OR

General Provider Information

NPI Number	:	1407037146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUALATIN PHYSICAL THERAPY & SPORTS REHAB INC

Provider Business Mailing Address
First Line	:	19767 SW 72ND AVE
Second Line	:	SUITE 102
City	:	TUALATIN
State	:	OR
Zip	:	97062-8354
Country	:	US
Telephone Number	:	503-885-2199
Fax Number	:	503-885-2129

Provider Business Practice Location Address
First Line	:	19767 SW 72ND AVE
Second Line	:	SUITE 102
City	:	TUALATIN
State	:	OR
Zip	:	97062-8354
Country	:	US
Telephone Number	:	503-885-2199
Fax Number	:	503-885-2129

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRYAN J CASPER
Credential	:	PT
Telephone Number	:	503-885-2199

Provider Enumeration Date	:	11/23/2007
Last Update Date	:	04/08/2011

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