Healthcare Provider Details

I. General information

NPI: 1275545311
Provider Name (Legal Business Name): NORTHWEST FOOTCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 02/23/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 SW CHANDLER AVE STE 280
BEND OR
97702
US

IV. Provider business mailing address

1693 SW CHANDLER AVE STE 280
BEND OR
97702
US

V. Phone/Fax

Practice location:
  • Phone: 541-385-7129
  • Fax: 541-385-7138
Mailing address:
  • Phone: 541-385-7129
  • Fax: 541-385-7138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRYAN D WILHELM
Title or Position: MANAGING PHYSICIAN
Credential: DPM
Phone: 541-385-7129