Healthcare Provider Details

I. General information

NPI: 1285127571
Provider Name (Legal Business Name): NICOLE TODISCO MACDONALD PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ANN TODISCO PT

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 03/21/2022
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SW CYBER DR STE 104
BEND OR
97702-1045
US

IV. Provider business mailing address

1645 NE SHEPARD RD
BEND OR
97701-4164
US

V. Phone/Fax

Practice location:
  • Phone: 802-318-2254
  • Fax:
Mailing address:
  • Phone: 802-318-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62809
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500744539
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: