# PROACTIVE ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF GRESHAM LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467413179
- **Authorized official:** MR. LARRY DEAN KROUT (MANAGING MEMBER)
- **Authorized official phone:** (503) 740-8847

## Contact information

- **Practice address:** 25500 SE STARK ST, SUITE 103, GRESHAM, OR 97030-3331
- **Practice address phone:** (503) 328-0222
- **Practice address fax:** (503) 328-0223
- **Mailing address:** PO BOX 52194, DEPT CODE 961, PHOENIX, AZ 85072-2194
- **Mailing address phone:** (503) 489-1781
- **Mailing address fax:** (503) 489-1650

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QP2000X | Physical Therapy Clinic/Center | 20573 | OR | Yes |

## Other

- **Enumeration date:** 03/31/2006
- **Last updated:** 07/25/2008