Provider Demographics
NPI:1063548329
Name:WILLAMETTE SPINE CENTER PHYSICAL THERAPY & REHABILITATION, LLC
Entity type:Organization
Organization Name:WILLAMETTE SPINE CENTER PHYSICAL THERAPY & REHABILITATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-763-3525
Mailing Address - Street 1:2480 LIBERTY ST NE STE 140
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-6781
Mailing Address - Country:US
Mailing Address - Phone:503-763-3525
Mailing Address - Fax:503-763-3526
Practice Address - Street 1:2480 LIBERTY ST NE STE 140
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-6781
Practice Address - Country:US
Practice Address - Phone:503-763-3525
Practice Address - Fax:503-763-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR105769Medicare ID - Type Unspecified