NPIMap

Organization Active NPI

Custom Care Physical Therapy, LLC.

  • Physical Therapy Clinic/Center
  • Forest Grove, OR
National Provider Identifier
1508005026
Registry record updated May 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
CUSTOM CARE PHYSICAL THERAPY, LLC.
Practice address
3838 Pacific Ave
Forest Grove, OR 97116-2224
Phone
(503) 357-1706
Fax
(503) 270-5023
NPI assigned
Feb 5, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 24, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lauren Lee Mason
Title
General Manager
Phone
(503) 357-1706

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X 3440 OR
Physical Therapy Clinic/Center 261QP2000X Primary

Addresses

Primary practice location

3838 Pacific Ave
Forest Grove, OR 97116-2224

Mailing address

3838 Pacific Ave
Forest Grove, OR 97116-2224
Phone (503) 357-1706

Other identifiers 1

IdentifierTypeStateIssuer
136956MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090213000402 OR Part B Supplier - Clinic/Group Practice 0941365514 Receives reassigned benefits from 7 practitioners
Practice locations: Forest Grove, OR

National Provider Directory

National Provider Directory

Locations

2329 Pacific Ave
Forest Grove, OR 97116
Phone (503) 357-1706

1909 Mountain View Ln
Ste 100
Forest Grove, OR 97116
Phone (503) 357-1706

4150 Pacific Ave
Ste 100
Forest Grove, OR 97116
Phone (503) 357-1706

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1233792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653350400000",
    "number": "1508005026",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3838 PACIFIC AVE",
            "city": "FOREST GROVE",
            "state": "OR",
            "postal_code": "971162224",
            "telephone_number": "503-357-1706",
            "fax_number": "503-270-5023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3838 PACIFIC AVE",
            "city": "FOREST GROVE",
            "state": "OR",
            "postal_code": "971162224",
            "telephone_number": "503-357-1706",
            "fax_number": "503-270-5023"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM CARE PHYSICAL THERAPY, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-02-05",
        "last_updated": "2022-05-24",
        "certification_date": "2021-07-22",
        "status": "A",
        "authorized_official_last_name": "MASON",
        "authorized_official_first_name": "LAUREN",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "GENERAL MANAGER",
        "authorized_official_telephone_number": "503-357-1706"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "OR",
            "license": "3440",
            "primary": false
        },
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "136956",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Forest Grove, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.