Healthcare Provider Details

I. General information

NPI: 1457136293
Provider Name (Legal Business Name): PHYSIO KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19820 VILLAGE OFFICE CT STE 201
BEND OR
97702-2949
US

IV. Provider business mailing address

19820 VILLAGE OFFICE CT STE 201
BEND OR
97702-2949
US

V. Phone/Fax

Practice location:
  • Phone: 541-410-6132
  • Fax: 541-209-4619
Mailing address:
  • Phone: 541-410-6132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
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: JAMIE KREFTING
Title or Position: PT/OWNER
Credential: PT, DPT
Phone: 970-759-6077