# 111TH SQUARE FITNESS AND THERAPY, LLC

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

## Provider details

- **NPI number:** 1750521985
- **Authorized official:** MS. LINDA JOSEPHINE SANCHEZ (MAKER)
- **Authorized official phone:** (503) 256-5200

## Contact information

- **Practice address:** 11126 NE HALSEY ST, PORTLAND, OR 97220-2021
- **Practice address phone:** (503) 256-5200
- **Practice address fax:** (503) 253-7958
- **Mailing address:** 11126 NE HALSEY ST, PORTLAND, OR 97220-2021
- **Mailing address phone:** (503) 256-5200
- **Mailing address fax:** (503) 253-7958

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 0355 | OR | Yes |
| 2255A2300X | Athletic Trainer | 1333261 | OR | — |
| 225700000X | Massage Therapist | 15397 | OR | — |

## Other

- **Enumeration date:** 02/27/2009
- **Last updated:** 02/27/2009