Basic Information
Provider Information | |||||||||
NPI: | 1558347302 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THERAPEUTIC ASSOCIATES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAI CANYON PARK SPORT & SPINE PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | TIGARD | ||||||||
State: | OR | ||||||||
PostalCode: | 972247736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002198835 | ||||||||
FaxNumber: | 5034431402 | ||||||||
Practice Location | |||||||||
Address1: | 19017 120TH AVE NE BLDG 1 | ||||||||
Address2: | SUITE 111 | ||||||||
City: | BOTHELL | ||||||||
State: | WA | ||||||||
PostalCode: | 980119510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254893420 | ||||||||
FaxNumber: | 4254893421 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 10/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIFFORD | ||||||||
AuthorizedOfficialFirstName: | TODD | ||||||||
AuthorizedOfficialMiddleName: | ROBERT | ||||||||
AuthorizedOfficialTitleorPosition: | INFORMATION SYSTEMS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5034436156 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.