Healthcare Provider Details

I. General information

NPI: 1750367256
Provider Name (Legal Business Name): CHARLES EDMAN BROCKMAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHUCK BROCKMAN

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 202, TAI - CENTRAL OREGON BEND
BEND OR
97701-4281
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE. 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-7738
  • Fax: 541-312-0121
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3101
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1653
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number912
License Number StateNV

VII. Legacy identifiers

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

# 1
IdentifierP00952506
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRR MEDICARE
# 2
Identifier181409
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: