Provider Demographics
NPI:1992766612
Name:CANBY PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:CANBY PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-740-8847
Mailing Address - Street 1:PO BOX 52194
Mailing Address - Street 2:DEPT CODE 960
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:503-489-1781
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:308 N IVY ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3704
Practice Address - Country:US
Practice Address - Phone:503-263-6786
Practice Address - Fax:503-263-6451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3131261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000132Medicaid
OR000132Medicaid
ORR133068Medicare PIN