Provider Demographics
NPI:1487112553
Name:TABOR PEDIATRIC PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:TABOR PEDIATRIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:LIGHTHIPE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-522-1359
Mailing Address - Street 1:2224 SE 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3916
Mailing Address - Country:US
Mailing Address - Phone:503-522-1359
Mailing Address - Fax:
Practice Address - Street 1:2224 SE 53RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3916
Practice Address - Country:US
Practice Address - Phone:503-522-1359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1063626034Medicaid