Basic Information
| Provider Information | |||||||||
| NPI: | 1275860496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPORBERT | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
| FaxNumber: | 9712065203 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 PINE STREET | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
| FaxNumber: | 9712065203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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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 | 26193 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.