Basic Information
| Provider Information | |||||||||
| NPI: | 1922315043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC ASSOCIATES, INC | ||||||||
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| OtherOrganizationName: | TAI - CENTRAL OREGON REDMOND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 NW LARCH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419237494 | ||||||||
| FaxNumber: | 5415049153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2010 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIFFORD | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8002198835 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OR | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0555080007 | 05 | OR | MEDICAID | 500625609 | 05 | OR | MEDICAID |