Provider Demographics
NPI:1487699609
Name:REID, ROCKWOOD ILES (PT)
Entity type:Individual
Prefix:
First Name:ROCKWOOD
Middle Name:ILES
Last Name:REID
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1864
Mailing Address - Country:US
Mailing Address - Phone:503-288-2615
Mailing Address - Fax:503-288-0339
Practice Address - Street 1:1825 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1864
Practice Address - Country:US
Practice Address - Phone:503-288-2615
Practice Address - Fax:503-288-0339
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR237206Medicaid
OR237206Medicaid