1245234285 NPI number — CENTRAL CASCADES PHYSICAL THERAPY

Table of content: (NPI 1245234285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245234285 NPI number — CENTRAL CASCADES PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CASCADES PHYSICAL THERAPY
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:
Provider Other Organization Name Type Code:
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:
1245234285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRIVER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97707-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-576-2110
Provider Business Mailing Address Fax Number:
541-598-0489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87520 BAY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHRISTMAS VALLEY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97641-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-576-2110
Provider Business Practice Location Address Fax Number:
541-598-0489
Provider Enumeration Date:
06/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COCKRUM
Authorized Official First Name:
GROVER
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
C.E.O
Authorized Official Telephone Number:
541-576-2110

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1385 , 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)

  • Identifier: 808366001 . This is a "REGENCE BLUECROSS/BLUESHI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 269080 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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