MEDICARE: DAVID VANCE MCHENRY PT

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	4478	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861475675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID VANCE MCHENRY PT

Provider Business Mailing Address
First Line	:	11481 SW HALL BLVD
Second Line	:	STE 201
City	:	PORTLAND
State	:	OR
Zip	:	97223-8403
Country	:	US
Telephone Number	:	800-219-8835
Fax Number	:	503-443-1402

Provider Business Practice Location Address
First Line	:	4829 NE MARTIN LUTHER KING BLVD
Second Line	:	STE 101
City	:	PORTLAND
State	:	OR
Zip	:	97211-3351
Country	:	US
Telephone Number	:	503-283-8133
Fax Number	:	503-289-2312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2005
Last Update Date	:	11/09/2007

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