Provider Demographics
NPI:1386924934
Name:ADVANCE INJURY CARE AND MOVEMENT THERAPY LLC
Entity type:Organization
Organization Name:ADVANCE INJURY CARE AND MOVEMENT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:ROSKOPF
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-939-2524
Mailing Address - Street 1:11507 SW SHILO LN
Mailing Address - Street 2:STE E
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5923
Mailing Address - Country:US
Mailing Address - Phone:503-939-2524
Mailing Address - Fax:503-520-0514
Practice Address - Street 1:11507 SW SHILO LN
Practice Address - Street 2:STE E
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5923
Practice Address - Country:US
Practice Address - Phone:503-939-2524
Practice Address - Fax:503-520-0514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty