Provider Demographics
NPI:1447813084
Name:PROKALEO PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:PROKALEO PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-298-6351
Mailing Address - Street 1:153 NE JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-3183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12120 SW GARDEN PL
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8264
Practice Address - Country:US
Practice Address - Phone:971-256-8416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467996983Medicaid