Basic Information
| Provider Information | |||||||||
| NPI: | 1003334392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENCO | ||||||||
| FirstName: | DAVID | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 319 NE RUSSET ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972112815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032895571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2017 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 62406 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.