Provider Demographics
NPI:1538407093
Name:UPPER ECHELON FITNESS AND REHABILITATION
Entity type:Organization
Organization Name:UPPER ECHELON FITNESS AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:CREE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-501-8121
Mailing Address - Street 1:1420 NW 17TH AVE STE 388
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2447
Mailing Address - Country:US
Mailing Address - Phone:503-501-8121
Mailing Address - Fax:
Practice Address - Street 1:1420 NW 17TH AVE STE 388
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2447
Practice Address - Country:US
Practice Address - Phone:503-501-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3049111N00000X
OR5776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty