Provider Demographics
NPI:1992721294
Name:PRO-TECH SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:PRO-TECH SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:503-699-0045
Mailing Address - Street 1:16679 BOONES FERRY RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4365
Mailing Address - Country:US
Mailing Address - Phone:503-699-0045
Mailing Address - Fax:503-699-1911
Practice Address - Street 1:16679 BOONES FERRY RD
Practice Address - Street 2:SUITE 215
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4365
Practice Address - Country:US
Practice Address - Phone:503-699-0045
Practice Address - Fax:503-699-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR035985Medicaid
OR081911000OtherBLUE CROSS PROVIDER #
OR0967020001Medicare NSC