Provider Demographics
NPI:1215133152
Name:ORTHOPEDIC & TMJ PHYSICAL THERAPY CENTER
Entity type:Organization
Organization Name:ORTHOPEDIC & TMJ PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONRADES
Authorized Official - Suffix:
Authorized Official - Credentials:RT PHYSICAL THERAPIS
Authorized Official - Phone:503-777-6746
Mailing Address - Street 1:9204 SE MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-777-6746
Mailing Address - Fax:503-777-0023
Practice Address - Street 1:9204 SE MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:503-777-6746
Practice Address - Fax:503-777-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBFGMedicare PIN