1255882635 NPI number — SAMPSON PHYSICAL THERAPY, INC

Table of content: (NPI 1255882635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255882635 NPI number — SAMPSON PHYSICAL THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMPSON PHYSICAL THERAPY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHSIDE PHYSICAL THERAPY, INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255882635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 NW GREENWOOD AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97703-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-388-2681
Provider Business Mailing Address Fax Number:
541-388-9236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 NW GREENWOOD AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97703-2079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-388-2681
Provider Business Practice Location Address Fax Number:
541-388-9236
Provider Enumeration Date:
10/20/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAMPSON
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT/THERAPIST
Authorized Official Telephone Number:
541-388-2681

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  16869140 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)