Provider Demographics
NPI:1528268588
Name:360 DEGREE SPORTS MEDICINE & SPINE THERAPY LLC
Entity type:Organization
Organization Name:360 DEGREE SPORTS MEDICINE & SPINE THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-248-0360
Mailing Address - Street 1:1215 SE 8TH AVE.
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-248-0360
Mailing Address - Fax:503-334-3675
Practice Address - Street 1:1215 SE 8TH AVE.
Practice Address - Street 2:SUITE D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-248-0360
Practice Address - Fax:503-334-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3018261QP2000X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty