Fountain of Youth Physical Therapy LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

4954 Issued in OR

Legal business name

FOUNTAIN OF YOUTH PHYSICAL THERAPY LLC

Practice address

9860 SW Hall Blvd Ste A3
Tigard, OR 97223-8896

Phone

(503) 902-2123

NPI assigned

May 25, 2010

Organization subpart

No

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

Authorized official

Name

Laura L Waliczek, PT, DPT

Title

Physical Therapist

Phone

(503) 327-4195

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1274745600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1274745600000",
    "number": "1801115183",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "664 SW RUSTICA TER",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972257057"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9860 SW HALL BLVD STE A3",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972238896",
            "telephone_number": "503-902-2123"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUNTAIN OF YOUTH PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-25",
        "last_updated": "2010-05-25",
        "status": "A",
        "authorized_official_last_name": "WALICZEK",
        "authorized_official_first_name": "LAURA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PHYSICAL THERAPIST",
        "authorized_official_telephone_number": "503-327-4195",
        "authorized_official_credential": "PT, DPT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": "OR",
            "license": "4954",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Dawn Foster, MS, LPC
• Kloee Jean Foster
• Terese R Foster, PA-C
• Found Waters, LLC
• Foundations for Health, LLC
• Robyn Fountain
• Alana Brook Fowler
• Donald David Fox, D.C
• Jessica Lynn Fox, LCSW
• Maria T Fox, REGISTERED ASSOCIATE

• Physical Therapist in Tigard, OR
• Providers in Tigard, OR by specialty
• Physical Therapist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 25, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.