Provider Demographics
NPI:1194937722
Name:BACK IN MOTION SPORTS INJURIES CLINIC, LLC
Entity type:Organization
Organization Name:BACK IN MOTION SPORTS INJURIES CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:FORCUM
Authorized Official - Suffix:III
Authorized Official - Credentials:DC, DACBSP, CSCS
Authorized Official - Phone:503-524-9040
Mailing Address - Street 1:11385 SW SCHOLLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7167
Mailing Address - Country:US
Mailing Address - Phone:503-524-9040
Mailing Address - Fax:503-579-4727
Practice Address - Street 1:11385 SW SCHOLLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7167
Practice Address - Country:US
Practice Address - Phone:503-524-9040
Practice Address - Fax:503-579-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Not Answered175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116848Medicare ID - Type Unspecified