Healthcare Provider Details

I. General information

NPI: 1497385215
Provider Name (Legal Business Name): CAPACITY PERFORMANCE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61125 LODGEPOLE DR.
BEND OR
97702
US

IV. Provider business mailing address

61125 LODGEPOLE DR.
BEND OR
97702
US

V. Phone/Fax

Practice location:
  • Phone: 541-224-7485
  • Fax:
Mailing address:
  • Phone: 541-224-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. NICHOLAS DONALD HAGEN
Title or Position: DIRECTOR CAPACITY PERFORMANCE THERA
Credential: PT
Phone: 541-224-7485