Healthcare Provider Details

I. General information

NPI: 1902164908
Provider Name (Legal Business Name): JAY M DICHARRY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 SW SIMPSON AVE SUITE 200
BEND OR
97702-3542
US

IV. Provider business mailing address

805 SW INDUSTRIAL WAY SUITE 3
BEND OR
97702-1093
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-9045
  • Fax: 541-322-9044
Mailing address:
  • Phone: 541-585-2529
  • Fax: 541-585-2536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6798
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500646505
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: