Healthcare Provider Details

I. General information

NPI: 1962272757
Provider Name (Legal Business Name): ON THE GO KINESIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20886 DESERT WOODS DR
BEND OR
97702-2836
US

IV. Provider business mailing address

20886 DESERT WOODS DR
BEND OR
97702-2836
US

V. Phone/Fax

Practice location:
  • Phone: 573-680-2276
  • Fax:
Mailing address:
  • Phone: 573-680-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. JENNA WEIDINGER
Title or Position: OWNER/ PT
Credential: DPT
Phone: 714-356-4440