Provider Demographics
NPI:1215127873
Name:PORTLAND SPORTS MEDICINE & SPINE PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:PORTLAND SPORTS MEDICINE & SPINE PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:QUESNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-230-1744
Mailing Address - Street 1:1610 SE GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5615
Mailing Address - Country:US
Mailing Address - Phone:503-230-1744
Mailing Address - Fax:503-230-1745
Practice Address - Street 1:1610 SE GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5615
Practice Address - Country:US
Practice Address - Phone:503-230-1744
Practice Address - Fax:503-230-1745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR45032251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty