Provider Demographics
NPI:1750521985
Name:111TH SQUARE FITNESS AND THERAPY, LLC
Entity type:Organization
Organization Name:111TH SQUARE FITNESS AND THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:JOSEPHINE
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-256-5200
Mailing Address - Street 1:11126 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2021
Mailing Address - Country:US
Mailing Address - Phone:503-256-5200
Mailing Address - Fax:503-253-7958
Practice Address - Street 1:11126 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2021
Practice Address - Country:US
Practice Address - Phone:503-256-5200
Practice Address - Fax:503-253-7958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15397225700000X
OR13332612255A2300X
OR0355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty