Provider Demographics
NPI:1548443955
Name:CLACKAMAS PHYSICAL THERAPY ASSOCIATES, INC.
Entity type:Organization
Organization Name:CLACKAMAS PHYSICAL THERAPY ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLENE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-698-5500
Mailing Address - Street 1:11203 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7787
Mailing Address - Country:US
Mailing Address - Phone:503-698-5500
Mailing Address - Fax:503-698-5501
Practice Address - Street 1:11203 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7787
Practice Address - Country:US
Practice Address - Phone:503-698-5500
Practice Address - Fax:503-698-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1870174400000X, 261Q00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007646Medicaid
ORR103654Medicare PIN