# FOUNTAIN OF YOUTH PHYSICAL THERAPY LLC

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

## Provider details

- **NPI number:** 1801115183
- **Authorized official:** LAURA L WALICZEK PT, DPT (PHYSICAL THERAPIST)
- **Authorized official phone:** (503) 327-4195

## Contact information

- **Practice address:** 9860 SW HALL BLVD STE A3, TIGARD, OR 97223-8896
- **Practice address phone:** (503) 902-2123
- **Mailing address:** 664 SW RUSTICA TER, PORTLAND, OR 97225-7057

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 4954 | OR | Yes |

## Other

- **Enumeration date:** 05/25/2010
- **Last updated:** 05/25/2010