Organization
FOUNTAIN OF YOUTH PHYSICAL THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA L WALICZEK PT, DPT (PHYSICAL THERAPIST)
(503) 327-4195
Entity
Organization
Contact information
Practice address
9860 SW HALL BLVD STE A3, TIGARD, OR 97223-8896
(503) 902-2123
Mailing address
664 SW RUSTICA TER, PORTLAND, OR 97225-7057
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
4954
OR
Other
Enumeration date
05/25/2010
Last updated
05/25/2010
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