# GREEN HERON PHYSICAL THERAPY LLC

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

## Provider details

- **NPI number:** 1518558469
- **Authorized official:** MARIO URDANETA-MONCADA DPT (OWNER, PHYSICAL THERAPIST)
- **Authorized official phone:** (661) 717-9692

## Contact information

- **Practice address:** 1706 NW 24TH AVE UNIT 96034, PORTLAND, OR 97296-6613
- **Practice address phone:** (661) 717-9692
- **Mailing address:** PO BOX 96034, PORTLAND, OR 97296-6000
- **Mailing address phone:** (661) 717-9692

## Taxonomy

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

## Other

- **Enumeration date:** 02/02/2021
- **Last updated:** 02/02/2021