Provider Demographics
NPI:1487789657
Name:GRESHAM SPORTSCARE
Entity type:Organization
Organization Name:GRESHAM SPORTSCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:EISCHEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:503-491-1666
Mailing Address - Street 1:24076 SE STARK ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3373
Mailing Address - Country:US
Mailing Address - Phone:503-491-1666
Mailing Address - Fax:
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:STE. 200
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-491-1666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1517261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy