Healthcare Provider Details

I. General information

NPI: 1003149485
Provider Name (Legal Business Name): CORE PHYSICAL THERAPY AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 SW CYBER DR STE 107
BEND OR
97702-1682
US

IV. Provider business mailing address

336 SW CYBER DR STE 107
BEND OR
97702-1682
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-6595
  • Fax:
Mailing address:
  • Phone: 541-389-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1543
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JENNIFER BRASSFIELD
Title or Position: CO-OWNER/PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 541-389-6595